Objective To evaluate the clinical response of target-controlled infusion-based anesthesia using remifentanil and propofol. Methods 40 ASA Ⅰ-Ⅱ patients (21 male, 19 female) aged 65 yr undergoing elective laparoscopic cholecystectomy were randomly divided into two groups: group F and R, each 20 patients, without any preoperative medication in group F the target plasma concentration of propofol was set at 3 μg/ml and fentanyl at 4 μg/kg during induction and 2 μg/kg at the start of operation. In group R, the anesthesia was induced and maintained with TCI propofol-remifentanil which was stopped at the end of the operation. The target plasma concentration of propofol was set at 3 μg/ml and remifentanil at 6 ng/ml. The TCI system of Base Primea was used, including Marsh and Minto pharmacokinetic parameters. MAP, HR, EKG, BIS and AAIs were monitored during the anesthesia. The followings were recorded: ①changes in MAP, HR, EKG, BIS and AAIs during anesthesia; ②recovery of spontaneous breathing and orientation after termination of anesthesia; ③postoperative outcome, pain and complications including nausea, vomiting and awareness during the operations. Results During induction MAP, the HRs were significantly lower in group R than in group F (P0.05). BIS and AAIs during operation were not significantly different. The duration from termination of anesthetics to full recovery of spontaneous breathing, eye opening at request and tracheal extubation were similar between the two groups. Pain after operation was significantly higher in group R than that in group F. Conclusions Anesthesia with the target plasma propofol concentration of 3 μg/ml in the presence of plasma remifentanil of 6 ng/m is safe and effective. It can effectively attenuate the intubation response. Because of the shorter context-sensitive half life of remifentanil, postoperative analgesia should be started earlier.

目的:对不同剂量戊乙奎醚作为术前用药的安全性和有效性进行临床观察.方法:选择ASAI-Ⅱ级病人30例,按照戊乙奎醚的剂量大小分为3组,即低剂量组、中剂量组和高剂量组.采用芬太尼、硫苯妥钠、琥珀胆碱快速静脉诱导,异氟醚吸入全麻维持,间断追加维库溴胺和芬太尼维持肌松和镇痛.记录无创血压、心电图、脉搏氧饱和度、体温和呼吸频率,唾液分泌量、口干程度、麻醉苏醒时间和拔管时间分别记录.结果:3组病人的组内比较表明各时间点血流动力学、呼吸频率和体温与基础值比较无显著差异(P＞0.05),各时间点的组间各值比较亦无显著差异(P＞0.05);对唾液分泌量和口干程度而言,肌注药物后30min和术后1h较基础值有显著差异(P＜0.05),以上两个时间点的不同剂量的组间比较表明,以高剂量组的肌注后30min的唾液分泌量和口干程度最明显(P＜0.05),术后1h时间点3组之间的唾液分泌量和口干程度之间无显著差异(P＞0.05).结论:戊乙奎醚低、中和高剂量均可以安全和有效的作为全麻病人的术前用药,减少围术期唾液腺的分泌和口干程度持续时间更长.

Objective Elderly patients with reduced cardiac function are not considered good candidates for acute isovolemic hemodilution ( AIH) and acute hypervolemic hemodilution ( AHH) significantly increases preload in these patients. We tried to develop an in-between technique, acute non-isovolemic hemodilution (ANIH). The purpose of this study was to evaluate the effectiveness and safety of ANIH in the elderly patients in comparison with AHH.Methods Thirty-eight ASA Ⅰ -Ⅱ patients of both sexes, aged between 65-80 yr, undergoing elective surgery were enrolled in this study. Their preoperative Hct was 35 % and the intraoperative blood loss was expected to be 800-1 600 ml. The operations were performed under combined general-epidural anesthesia. General anesthesia was induced with fentanyl 2-4 μg·kg-1 , thiopentone 5 mg·kg-1 and succinylcholine 1.5mg· kg-1 and maintained with isoflurane inhalation and intermittent iv boluses of vecuronium. Epidural anesthesia was performed at T5-6 (thoracic surgery), T10-11 (upper abdominal surgery) or L3-4 (lower abdominal surgery) . A mixture of 0.1% lidocaine +0.2% dicaine was used for epidural block during operation. The patients were randomly divided into 2 groups: (1) ANIH group ( n = 18) and (2) AHH group ( n = 20) . Blood volume (BV) was calculated according to following formula: BV (ml) (male) = Height (cm)× 28.5 + Body weight (kg) × 31.6 - 2 820,BV(ml) (female) = Height(cm)× 16.25 + Body weight (kg) × 38.46 - 1 369. 1 000-1 200 ml of 6% HES (200/0.5) and 500 ml of lactated Ringer's solution (about 25%-30% of BV) were infused at a rate of 50ml·min-1 when induction of anesthesia was started in both groups. In group I (ANIH) 400-600 ml of blood (about 10%-15% of BV) was removed through radial artery before induction of anesthesia. The removed blood was reinfused at the end of surgery. Vital signs (BP,HR,CVP and ST-T changes) , Hct, oncotic pressure and arterial blood lactate concentration were monitored during operation. Results The vital signs were fairly stable during perioperative period in both groups. Transient hypotension developed in 16.7% (3/8 in group Ⅰ ) and 15.0% (3/20 in group Ⅱ ) of patients during induction of anesthesia. CVP was significantly elevated in both groups but the increase in CVP was significantly higher in group Ⅱthan that in group Ⅰ . In group Ⅰ (AN1H) moderate hemodilution was achieved (Hct = 29.9% 2.9%) while in group Ⅱ (AHH) only mild hemodilution was achieved (Hct = 32.9% ±2.9%) .Hct was significantly higher in group Ⅰ(31.5% ±5.1%) than that in group Ⅱ (27.7% ±3.6%) at the end of surgery. Blood loss was comparable between the two groups, and oncotic pressure and blood lactate level were within normal range in both groups. Conclusion ANIH is more effective and safer than AHH without obvious adverse effects, and can avoid exceedingly high CVP commonly seen in AHH. ANIH is a hemodilution technique of choice in the elderly patients.