三叉神经痛是最常见的脑神经疾病,以三叉神经分布区内反复发作的阵发性剧烈疼痛为主要表现.1913年,Rethi首次使用电凝三叉神经外周分支的方法治疗三叉神经痛.近年来,三叉神经的射频热凝术的术式被不断改进,主要方法为在影像引导下将穿刺针经皮穿刺至颅底卵圆孔内,先使用电生理方法定位,然后利用射频热凝来毁损三叉神经半月节,从而达到阻断痛觉传导的目的.三叉神经射频热凝术已经成为了疼痛科常用微创治疗手段,具有创伤小、可控性强、即时疼痛缓解率高的优点,但是就该手术的远期疗效而言,相关影响因素尚有争议 [1～3].目前判断该手术的疗效和预后的方法主要依赖问诊、查体和医师的经验,缺乏客观的评估指标.为了探讨电生理检测用于预判三叉神经射频热凝术的远期疗效的价值,本研究首次在三叉神经的射频热凝术的围术期对病人进行瞬目反射(Blink reflex, BR)检测,并在术后连续随访7年,分析了BR波形特征与手术疗效、复发率和术后并发症的关系,现探讨如下.

目的 探讨右旋美托咪啶对室上性心动过速(以下简称“室上速”)患儿七氟烷麻醉血流动力学及苏醒期躁动的影响.方法 选取2013年1月～2017年8月在清华大学第一附属医院北京华信医院行射频消融术的室上速患儿63例,按照随机数字表法将患儿分为A、B、C三组,每组各21例.术前A组静脉注射右旋美托咪啶0.3 μg/kg,B组静脉注射右旋美托咪啶0.5 μg/kg,C组(对照组)静注生理盐水.观察比较手术开始后静脉注射生理盐水及右旋美托咪啶组注射前(T0)、注射后5 min(T1)、注射后10 min(T2)、患儿清醒时(T3)、拔喉罩后5 min(T4)、拔喉罩后10 min(T5)的有创平均动脉压(MAP)、心率(HR);记录三组患儿手术时间、苏醒时间、拔管时间并采用小儿麻醉后苏醒躁动(PAED)评分量表和Watcha评分评估三组患儿苏醒后躁动情况,记录躁动持续时间＞15 min的发生率;记录术后不良反应发生情况.结果 与T0比较,A组和C组T3～T5时MAP、HR值均明显升高,差异有统计学意义(P＜0.05);B组各时间点MAP、HR值比较,差异无统计学意义(P＞0.05);与C组比较,A组和B组T3～T5时MAP、HR值显著降低,且B组T3～T5时MAP、HR值低于A组,差异均有统计学意义(P＜0.05).与C组比较,A组、B组PEAD评分、Watcha评分、躁动持续时间＞15 min的发生率均明显降低,且B组显著低于A组,差异均有统计学意义(P＜0.05).治疗后,A组及B组总不良反应发生率(23.80％、9.52％)均低于C组(57.14％),且B组低于A组,差异均有统计学意义(P＜0.05).结论 右旋美托咪啶可以有效缓解室上速小儿七氟烷全麻苏醒期躁动发生,改善血流动力学变化,降低不良反应的发生,值得临床推广.

目的 探讨心脏外科手术中采用七氟醚联合瑞芬太尼实施全身麻醉对患者认知功能、凝血功能的影响.方法 选取我院2016年3月-2017年12月拟实施心脏手术的患者90例,采用随机数字表法分为A组、B组,各45例,A组采用七氟醚联合瑞芬太尼实施全身麻醉,B组采用七氟醚+异丙酚+舒芬太尼实施全身麻醉,对比两组患者不同时间点的平均动脉压(MAP)、心率(HR)、简易智力状态检查量表(MMSE)、凝血酶原时间(PT)、凝血酶时间(TT)、活化部分凝血酶时间(APTT)、认知功能障碍(POCD)的发生率.结果 A组和B组患者的HR、MAP测定值在T0～T4时刻进行组间比较,差异均无统计学意义(P＞0.05);A组和B组患者的HR、MAP在T1、T2、T3、T4时刻较T0时刻均呈现出显著的波动(P＜0.05);术前,A组和B组患者的MMSE评分比较,差异均无统计学意义(P＞0.05);术后1d、术后3d,A组MMSE评分均显著高于B组患者(P＜0.05);术后7d,两组患者的MMSE评分差异无统计学意义(P＞0.05);术前,A组和B组患者的PT、APTT、TT测定值比较,差异均无统计学意义(P＞0.05);术后12 h,A组PT、TT均显著高于B组患者(P＜0.05);术后,A组的POCD发生率22.22％低于B组的42.22％,差异具有统计学意义(P＜0.05).结论 心脏外科手术中采用七氟醚联合瑞芬太尼实施全身麻醉有利于减少患者术后POCD的发生,同时减少对患者凝血功能的影响.

患儿男，生后1 h，主因“发现先天性完全性房室传导阻滞”于2016年4月入住清华大学第一附属医院心脏小儿科。母亲孕25周时发现胎儿心率慢，超声检查提示胎儿房室传导阻滞，孕35周超声提示胎儿完全性房室传导阻滞（心房率135次／min，心室率44次／min），全心扩大，心胸比例0．7，左室舒张末内径20 mm，射血分数59％，心脏结构未见异常。胎儿期生长发育尚正常，胎龄36周剖宫产出生，出生体重为2．5 kg，1、5、10 min Apgar评分分别为9、9、10分。为行“起搏治疗”收入我科。患儿为第2胎第2产，其姐姐（12岁）体健，出生史及既往史无特殊，母亲（43岁）和父亲（44岁）既往体健，否认晕厥、猝死家族史，母亲自身抗体谱［抗核抗体、干燥综合征（ SS ）－A、SS－B、双链DNA （ dsDNA ）抗体、抗心磷脂抗体等］阴性。

Objective To evaluate the efficacy of radiofrequency ablation performed under sevoflurane anesthesia in the pediatric patients with ventricular premature beats (VPBs).Methods Twenty American Society of Anesthesiologists physical status Ⅰ or Ⅱ pediatric patients,with non-organic heart disease and VPBs,aged 3-12 yr,weighing 19-53 kg,undergoing elective radiofrequency ablation,were divided into propofol group (Pro group) and sevoflurane group (Sev group) using a random number table.Anesthesia was induced with midazolam 0.05 mg/kg,sufentanil 0.3-0.5 μg/kg,propofol 2.5-4.0 mg/kg (in Pro group) and 8％ sevoflurane (in Sev group).Supreme laryngeal mask airway was placed when eyelash reflex disappeared.Propofol 6 mg· kg-1 · h-1 was intravenously infused in Pro group,and 2％-3％ sevoflurane was inhaled in Sev group,and bispectral index value was maintained at 50-60.The frequency of VPBs developed was recorded before induction and at 1,5 and 10 min after induction,and the recurrence was observed within 1 month after operation.Results Compared with that before induction,the frequency of VPBs developed was significantly decreased at 1,5 and 10 min after induction in Pro group (P＜0.05),and no significant change was found in Sev group (P＞0.05).The frequency of VPBs developed was significantly higher at 1,5 and 10 min after induction in Sev group than in Pro group (P＜0.05).The recurrent rate was 30％ within 1 month after operation in Pro group,no recurrence was found in Sev group,and there was significant difference between Sev group and Pro group (P＜0.05).Conclusion The efficacy of radiofrequency ablation performed under sevoflurane anesthesia is better than that performed under propofol anesthesia in the pediatric patients with VPBs.

Objective: This study aimed to evaluate the application value of portable ultrasound on clinical judgment of endotracheal tube placement. Methods: This was a blinded prospective study. A total of 94 ASAI similar to III patients in Beijing Chaoyan hospital from September, 2013 to February 2014, were randomly selected. All patients were intended to perform routine orotracheal intubation under general anesthesia. The tracheal intubations with laryngoscopy were performed by residents, 10 mL of saline were injected up to the endotracheal tube cuff (COVIDIENTM. MallinckrodtTM. Taper Guard Evac Oral Tracheal Tube). The endotracheal tube placement (in the trachea or in the esophagus) was confirmed by ultrasound scanning of the neck. End tidal CO2 (ETCO2) wave combined with chest ausculation were used as the gold standard of successful tracheal intubation. Sensitivity, specificity, positive predictive value and negative predictive value of endotracheal tube placement were calculated. Software SPSS 17.0 was used for statistical analysis. Results: Ninety-three patients were enrolled (ASAI similar to III) in this study with 42 males and 51 females. The mean age of the 93 patients was 53.5 +/- 11.8 years old; BMI was 24.91 +/- 3.38. Esophageal intubation was detected in 9 patients. One case of esophageal intubation was misdiagnosed by sonography. The sensitivity and specificity of ultrasonic localization of tracheal intubations was 100% (95% confidence interval, 94.6%-100%) and 88.9% (95% confidence interval, 84%-100%) with the positive and negative predictive value of 98.8% (95% CI 92.7-99.9) and 100.0% (95% CI 59.8-100) respectively. Conclusion: Sonography is portable, non-invasive and repeatable method; it could be used to confirm intracheal intubation with a relatively high sensitivity and specificity.

Objective To evaluate the features and management methods of anesthesia for infants with rapid arrhythmia undergoing radiofrequency catheter ablation.Methods One hundred and twenty-three infants with rapid arrhythmia undergoing radiofrequency catheter ablation were retrospectively analyzed in this study.All infants were given combined anesthesia while using laryngeal mask to manage airway.Record the success rate of operation,anesthesia time,operation time and related complications.Results Of the included 123 cases,the operation of 109 cases were finished with successful rate of 95.4％(104/109).The mean operation and anesthesia time were (86.38±33.52) min and (92.28±37.19) min respectively.The operation of 6 cases were not performed due to unsuccessful induction of tachycardia.There are 5 cases of postoperation agitation,4 cases of laryngeal spasm were disappeared after deepen anesthesia.1 case of larygeal spasm was discharged to patient unit.The laryngeal spasm was disappeared until intubation for 3 h.There are total 3 cases of postoperation nausea and vomiting.Conclusions Radiofrequency catheter ablation of infants and young children with rapid arrhythmia had high risk and high incidence of anesthesia related complications.Good management of hemodynamics and airway,reasonable selection of narcotic are the key management of this kind of anesthesia.

Objective To compare the anesthetic effect of different inserting time on patients under propofol combined sufentanil anesthesia in gastroscopy.Methods A total of 120 out-patients aged 18-60 years underwent gastroscopy were randomly divided into two groups (A and B,60 cases each).They received sufentanil 0.1μg/kg combined with propofol 1.5 mg/kg intravenously.Gastros-copy was inserted into patients’mouth immediately when the patients’consciousness lost and eyelash reflex disappeared (group A)or 30 s later (group B).When necessary (cough or movement),addi-tional propofol 0.5 mg/kg was added to enhance and maintain anesthesia.HR,BP and SpO2 were re-corded before induction (T0 ),before inserting (T1 ),gastroscopy passing through throat (T2 )and after procedure (T3 ).We observed and recorded cough,hiccup,body movement,recovery time and total dosage of propofol.Results Compared with T0 ,MAP (T1 )of both groups were lower (P <0.05).There was no statistic different in MAP on T2 and T3 .There was no statistic different in HR, MAP and SpO2 on T0-T3 between two groups.The incidence of cough and body movement were lower in group B than in group A (P <0.05).Group B had shorter recovery time and less propofol usage than group A (P <0.05).Conclusion Inserting gastroscopy 30 s after consciousness and eyelash re-flex disappear in propofol combined sufentanil anesthesia can reduce the incidence of cough and move-ment,reduce propofol consumption,and shorten recovery time but without respiratory and haemody-namic adverse effects.

患者，男，60岁，60 kg，因右房肿瘤拟于全麻低温 CPB下行右房肿瘤切除术，既往无手术史。患者入院时颈静脉充盈，平卧后头面部肿胀，半坐位后好转，予强心、利尿治疗后，症状好转。心脏彩超：右房42 mm，顶部占位2.5 cm×5.5 cm×10 cm，占右房容积50％～60％，并部分堵塞上腔静脉入口，与心房壁广泛粘连，未见累及下腔静脉。心脏 MRI：右心房及肝左叶占位，伴上腔静脉梗阻，考虑心脏肉瘤可能。心电图：频发房早。Holter：频发房早、室早。肺功能正常。胸片：慢支样改变，心胸比0.51。术前检查：BNP 581 ng／L，血常规、肝肾功能、电解质、动脉血气、凝血功能基本正常。

患儿,男,3岁,92 cm,13 kg,因“先天性心脏病,法洛四联症,体肺分流术后,声门下狭窄”拟行声门下狭窄松解术。患儿出生后40 d,因咳嗽就诊,心脏彩超示“先天性心脏病,法洛四联症”,肺动脉及左心室发育差,于我院行体肺分流术。术后1年肺动脉及左室发育尚好,欲行法洛四联症根治术。术中喉镜示声门下环形狭窄,气管插管困难,取消手术。患儿本次于2015年入院后,监测吸纯氧条件下 SpO 285%~90%,步行50 m 出现气喘,口唇发绀。CT 增强扫描示：右室横截面积3.1~4.8 cm2,右室壁增厚,左室体积与右室相当；室间隔缺损直径约0.7 cm,肺动脉发自右心室,右室流出道狭窄,最窄处直径约0.5 cm,肺动脉瓣环狭窄,瓣叶增厚；主动脉骑跨,骑跨率为50%,升主动脉右侧可见管状连接于右肺动脉。颈椎 CT 示：主气管局部环形狭窄,狭窄长度约2.2 mm,最窄处直径4.6 mm。其他辅助检查未见异常。术前全院会诊拟定气管插管全麻,备用方案为“保留自主呼吸下静脉麻醉并保证气道通畅高氧大流量给氧”,拟行声门下狭窄松解术。

目的 对比观察地佐辛和氯胺酮用于紫绀型复杂先天性心脏病(CCHD)导管造影麻醉的临床效果和安全性.方法 2014年1月至2015年4月清华大学第一附属医院择期行心导管造影术的6岁以下CCHD患儿64例,用抽签法随机分为地佐辛组(D组)和氯胺酮组(L组),每组32例.D组静注地佐辛0.2 mg/kg,L组静注氯胺酮2.0 mg/kg,静脉诱导后置入喉罩,以吸入2.0％～2.5％七氟烷维持麻醉.观察注药后患儿入睡时间(T1)、拔管后面罩辅助通气时间(T2)、苏醒时间(T3)、气道痉挛、呼吸抑制、躁动、疼痛及恶心呕吐等不良反应.结果 D组患儿T1长于L组(P＜0.05),T3短于L组(P＜0.05),诱导期或者拔管后血氧饱和度下降＞20％和吸痰2次以上的例数明显少于L组(P＜0.05),余差异无统计学意义.结论 地佐辛0.2 mg/kg静脉注射可安全用于紫绀型CCHD患儿导管造影麻醉,可提供满意的术前镇静和术后镇痛,且呼吸道不良反应发生率低于氯胺酮.

目的：探究地佐辛应用于小儿快速型心律失常射频消融术的安全性和有效性。方法择期行射频消融术的心律失常患儿160例，按入院先后顺序分成地佐辛组（ D组）和生理盐水组（ S组）。两组均以静脉诱导后置入喉罩，以2％七氟烷维持麻醉。手术结束前15 min，D组予地佐辛0.1 mg/kg，S组予生理盐水1 ml，观察拔管后自主呼吸恢复时间、苏醒时间，喉痉挛、躁动、恶心呕吐、头晕、疼痛及呼吸抑制等不良反应。结果地佐辛组术后躁动及疼痛发生率明显低于生理盐水组，并且苏醒时间明显长于生理盐水组，两组比较差异有统计学意义（ P ＜0.05）；两组自主呼吸恢复时间、呼吸抑制、恶心呕吐、头晕及喉痉挛发生率差异无统计学意义（ P ＞0.05）。结论手术结束前15 min静脉予地佐辛0.1 mg/kg在小儿快速型心律失常的射频消融术后可维持满意的镇痛和镇静效果，不良反应发生率低，具有良好的临床安全有效性。

目的：观察右美托咪定联合地佐辛对臂丛神经阻滞麻醉效果的影响。方法将90例拟行上肢手术的患者按随机数字表法分为Ⅰ、Ⅱ、Ⅲ组各30例，臂丛阻滞后10 min，Ⅰ组静注右美托咪定0．5μg/kg，继以微量泵静注0．4μg/（ kg· h）；Ⅱ组静注地佐辛0．1 mg/kg，继以微量泵静注生理盐水20 mL/h；Ⅲ组静注右美托咪定0．5μg/kg和地佐辛0．1 mg/kg，继以微量泵静注右美托咪定0．4μg/（kg· h）。记录3组臂丛阻滞神经麻醉前（T0），臂丛神经阻滞麻醉后10 min（ T1），上止血带时（ T2），手术开始后5 min（ T3）、30 min（ T4），手术结束时（ T5）的MAP、HR、SpO2和Ramsay镇静评分；记录术中不良反应及术后VAS。结果3组T2时点MAP均高于其他时点，Ⅰ组T2时点MAP、HR均高于Ⅱ、Ⅲ组，P均＜0．05。Ⅰ、Ⅲ组T2～T5时点Ramsay镇静评分均高于Ⅱ组，P均＜0．05。Ⅰ、Ⅱ、Ⅲ组术后VAS分别为（4．1±0．4）、（1．5±0．5）、（1．4±0．6）分，Ⅰ组与Ⅱ、Ⅲ组比较，P均＜0．05。3组均未出现呼吸抑制、严重低血压、低血氧等不良反应。结论右美托咪定联合地佐辛能够增强臂丛神经阻滞麻醉的镇静、镇痛效果，且安全性较好。

目的 评价地佐辛复合依托咪酯麻醉在门诊患者无痛胃镜术中的应用效果.方法 将行无痛胃镜术的80例患者(ASAⅠ～ Ⅱ级)随机分为地佐辛组(D组,n=40)和舒芬太尼组(S组,n=40)分别静脉注射地佐辛20μg/kg和舒芬太尼0.1μg/kg;3 min后两组患者均注射依托咪酯0.2mg/Kg.分别于注药前(T1),睫毛反射消失时(T2)和定向力恢复时(T3)记录各组的平均动脉压(MAP)、心率(HR)和脉搏氧饱和度(SpO2).结果 与TI时比较,T2时各组MAP、HR、SpO2均明显下降,D组MAP、SpO2下降缓和,与S组的差异有统汁学意义(P＜0.05),D组呼吸抑制的发生率明显少于S组(P＜0.05).D组苏醒时间较S组明显缩短(P＜0.05).结论 地佐辛复合依托咪酯麻醉用于门诊患者的无痛胃镜术,可稳定循环和呼吸功能,缩短苏醒时间.

患儿,女,7岁11月,体重15 kg,因先天性心脏病、法四型右室双出口、右室流出道梗阻、房间隔缺损、右肺支气管发出畸形、左室发育和运动耐量差,于6个月前行体-肺分流术,术后SpO2 85％,运动耐量明显改善,为行根治术二次入院.术前SpO 85％,Hb 168 g/L,Hct 51.3％.动脉血气:pH 7.443,PaCO2 27.5 mm Hg,PaO2 49.7 mm Hg,SaO287.2％,凝血功能正常.心脏彩超示:法四型右室双出口、房间隔两处缺损(分别9.5mm和8.5 mm)、室间隔缺损(23mm)、主动脉骑跨率90％、右室流出道内径3mm、肺动脉瓣环内径10 mm、左右肺动脉发育可、左心室舒张/收缩内径31/22mm、升主动脉前壁可见直径3.5mm人工管道血流通畅、未见明确体肺侧枝形成、永存左上腔静脉.胸部X线片示:心胸比0.6,肺血大致正常,右心增大为主.

心脏电生理研究的不断发展使越来越多的心律失常患者通过介入治疗得到康复,就诊患者也由成人向儿童群体扩展,近年来心律失常患儿行射频消融术者逐渐增多,小儿因其生理、心理上的特殊性,需要一定的麻醉支持,以往多采用气管插管全麻或深度镇静麻醉,但两种方法均存在较大缺点：气管插管全麻过程复杂,麻醉恢复时间长,而大多数导管室内缺乏麻醉恢复条件,术后常需转入 PACU 或 ICU,转运过程复杂且影响手术周转率；深度镇静麻醉药物用量不易控制,麻醉过深易引起呼吸抑制。我院既往多采用深度镇静麻醉,自小儿喉罩应用于临床后,我院即开始尝试喉罩通气下全麻,取得了良好的效果,现就关于喉罩通气下全麻应用于患儿心律失常射频消融术的麻醉总结如下。

患儿,女,3岁4个月,体重14.3 kg,因室性早搏于全麻下行心脏电生理检查+射频消融术.患儿发育正常,无其他疾病史.术前检查:WBC 10.12×109/L,Plt 533×109/L,凝血酶原时间(PT) 11.1 s,部分凝血活酶时间(APTT)35 s,凝血酶时间(TT) 22 s,纤维蛋白原(FIB)2.56 g/L;肝肾功能及电解质正常.ECG示频发室早,心脏彩超未见明显异常. 入室后静脉推注舒芬太尼5μg、咪达唑仑1mg、丙泊酚60 mg诱导,置入2# Supreme喉罩,术中以2％七氟醚维持麻醉.经心脏电生理检查证明,室早起源位于左室中后间隔,需经右股动脉置入导管消融.穿刺动脉前常规静推肝素700U,每小时追加350 U.手术历时3.5h.术后常规压迫右股动脉0.5h,并监测同侧足部SpO2,以了解右股动脉是否通畅.压迫5 min即止血,右下肢皮肤发白,温度低于对侧,不能扪及右股动脉、右足背动脉,足部SpQ亦消失.可疑股动脉血栓形成,立即静推肝素350 U,5min后监测ACT 103 s.

病历摘要 患儿男,2岁3个月,因发现心脏杂音2个月,于2011年7月29日收住入清华大学第一附属医院.患者人院前2个月,因感冒就诊于当地医院,查体发现心脏杂音.随后患儿入我院治疗.患儿发育较正常小儿稍差,身高82 cm,体质量10 kg.四肢末梢经皮血氧饱和度:98％～100％.心脏听诊:胸骨右缘第2肋间可闻收缩期Ⅱ～Ⅲ/6级杂音,胸骨左缘第4～5肋间可闻及舒张期中度杂音.血压:上肢100/52 mm Hg(1 mm Hg =0.133 kPa),下肢54/39 mm Hg.经胸心脏彩超提示:主动脉瓣狭窄,压差69 mm Hg,瓣环内径10 mm,先天性主动脉瓣二瓣化畸形;二尖瓣瓣上隔膜,二尖瓣狭窄,瓣叶开放受限,压差15 mm Hg;主动脉弓部发出左锁骨下动脉以远局部狭窄,压差69 mm Hg;动脉导管未闭,直径6 mm;左室舒张末期内径34mm,射血分数65％.

目的 观察右美托咪啶用于预防和降低高血压病人气管拔管心血管应激反应的有效性和安全性.方法 选择患有原发性高血压1～2期择期在气管插管全麻下行经腹腔镜胆囊切除术ASAⅡ～Ⅲ级病人72例,随机分为右美托咪啶组(D组)和对照组(N组),每组各36例,术前所有病人血压控制在160/90mmHg以下,分别于手术结束后拔管前静脉微泵右美托咪啶0.5μg/kg或等剂量生理盐水.观察麻醉前、用药后、拔管前、拔管即刻、拔管后3、5、10号in病人HR、MAP、心肌氧耗指数(RPP)、血浆去甲肾上腺素(NE)、肾上腺素(E)浓度.结果 ①与麻醉前相比,N组在T2、T3、T4 MAP、HR均明显升高(P＜0.05),而D组在上述时间点MAP、HR上升幅度较小,组间比较差异有统计学意义(P＜0.05);②RPP、NE、E在T2、T3、T4、T5D组均低于N组,组间比较有显著性差异(P＜0.05).结论 手术结束后静脉微泵注射右美托咪啶0.5 μg/kg能有效预防高血压病人全麻拔管期间的心血管应激反应,维持血液动力学稳定,可安全用于高血压病人的全麻气管拔管.