Chronic postsurgical pain (CPSP) is one of the major medical problems facing society, often with an adverse impact on a patient's quality of life after surgery. Although multimodal analgesia has been implemented in the perioperative period, some patients inevitably transit from acute to chronic pain (APSP). Individual differences among patients may be involved in the occurrence and development of CPSP. This review summarizes the risk factors that may cause postoperative CPSP from possible influence factors, including demographic characteristics such as age, gender, obesity, and smoking; the possible perioperative variables such as preoperative CPSP, quantitative sensory testing, type or modality of surgery, APSP, postoperative radiation therapy, and chemotherapy; psychological factors such as depression, anxiety, pain catastrophizing, and expected pain; and genetic factors, mainly referring to gene polymorphisms. Identifying these risk factors early can help identify high-risk patients and actively implement individual analgesic administration.

Objective:To evaluate the relationship between the mechanism underlying the antidepressant effect of S-ketamine and hippocampal gamma-aminobutyric acid B receptor (GABA BR) in mice. Methods:A total of 54 male C57BL/6(B6) mice, aged 8 weeks, weighing 25-30 g, were used in this study. Forty mice were selected to develop the depression model by chronic social defeat stress. Twenty-six depression-susceptible mice were screened out by social avoidance test at day 11 after developing the model and divided into 2 groups ( n=13 each) by a random number table method: depression-susceptible group (Sus group) and depression-susceptible + S-ketamine group (Sus + S-ket group). The remaining 14 mice served as control group (C group). Starting from day 12 after developing the model, S-ketamine 10 mg/kg was intraperitoneally injected every day for 3 consecutive days in Sus+ S-ket group, while the equal volume of normal saline was given instead in C group and Sus group. The open field test was performed at 1 h after the last administration, and the total distance of movement was recorded. The forced swimming test was performed at 1 day after the open field test, and the immobile time was recorded. The sucrose preference test was performed to calculate the proportion of sucrose consumption at 1 day after the forced swimming test. One hour after the end of behavioral test, mice were sacrificed, and the hippocampal tissues were removed. Western blot was used to detect the expression of GABA BR1, GABA BR2, mammalian target of rapamycin (mTOR), phosphorylated mTOR (p-mTOR), brain-derived neurotrophic factor (BDNF), tyrosine kinase receptor B (TrkB), phosphorylated TrkB (p-TrkB), glutamate receptor 1 (GluR1) and postsynaptic dense protein 95 (PSD95). The p-mTOR/mTOR ratio and p-TrkB/TrkB ratio were calculated. The fluorescence intensity of BDNF in hippocampal CA1 region was detected by immunofluorescence. The number of dendritic spines in hippocampal CA1 region was measured by Golgi staining. Results:In the open field test, no statistically significant difference in the total distance was detected among the three groups ( P>0.05). Compared with C group, the immobile time in the forced swimming test was significantly prolonged, the proportion of sucrose consumption was decreased, the expression of hippocampal GABA BR1, GABA BR2, BDNF, GluR1 and PSD95 was down-regulated, and the ratios of p-mTOR/mTOR and p-TrkB/TrkB were decreased, the fluorescence intensity of BDNF and total number of dendritic spines in the hippocampal CA1 region were decreased in Sus group ( P<0.05), and no significant change was found in the parameters mentioned above in Sus+ S-ket group ( P>0.05). Compared with Sus group, the immobile time in the forced swimming test was significantly shortened, the proportion of sucrose consumption was increased, the expression of hippocampal GABA BR1, GABA BR2, BDNF, GluR1 and PSD95 was up-regulated, the ratios of p-mTOR/mTOR and p-TrkB/TrkB were increased, and the fluorescence intensity of BDNF and total number of dendritic spines in the hippocampal CA1 region were increased in Sus+ S-ket group ( P<0.05). Conclusions:The mechanism underlying the antidepressant effect of S-ketamine may be related to up-regulation of hippocampal GABA BR expression, activation of mTOR-BDNF signaling pathway, and improvement in synaptic plasticity in mice.

近年来随着外科技术与设备的发展，腹腔镜手术因创伤小、恢复快、住院时间短和患者满意度高等优点，已经在外科领域广泛开展。与开腹手术麻醉管理相比，微创手术麻醉管理要求更高。腹腔镜手术常采用CO 2气腹，进而导致腹内压(IAP)升高，并引起特定的病理生理效应。因此，如何进行合理的肌松管理，减少气腹引起的不良反应，是该类患者麻醉管理的关键。本文就腹腔镜手术中气腹压力造成的病理生理影响、术中肌松程度管理、肌松监测以及术后肌松拮抗剂应用的研究进展进行综述。

目的 探讨复合阿芬太尼时瑞马唑仑抑制双腔支气管插管反应的半数有效剂量(ED50).方法 选择2022年5—7月行双腔支气管插管患者35例,男17例,女18例,年龄18～64岁,BMI 18～30 kg/m2,ASAⅠ—Ⅲ级.首例患者给予瑞马唑仑0.35 mg/kg,警觉/镇静评分(OAA/S评分)为0分时,给予阿芬太尼50μg/kg、罗库溴铵0.6 mg/kg后行气管插管.双腔支气管插管反应阳性定义为气管插管后2 min内HR或MAP升高幅度超过基础值的20％,否则为阴性反应.按照改良Dixon序贯法,设定相邻剂量梯度为0.05 mg/kg,若出现阳性反应,下一例患者升高1个剂量梯度;反之降低一个剂量梯度,观察到第7个阳性反应-阴性反应交叉点时终止试验.采用Probit回归分析计算瑞马唑仑ED50、ED95及其95％可信区间(CI).结果 共纳入患者35例,其中阳性反应15例(43％).瑞马唑仑抑制双腔支气管插管反应的ED50为0.206 mg/kg(95％CI 0.135～0.252 mg/kg),ED95为0.344 mg/kg(95％CI 0.283～0.691 mg/kg).诱导期间2例患者出现一过性低血压,无其他不良反应.所有患者均未发生术中知晓.结论 复合阿芬太尼时瑞马唑仑抑制双腔支气管插管反应的ED50为0.206 mg/kg,ED95为0.344 mg/kg.

Objective:To evaluate the effect of remazolam combined with remifentanil for general anesthesia in patients undergoing ophthalmic surgery.Methods:A total of 80 patients, American Society of Anesthesiologists (ASA) Ⅰ or Ⅱ grade, aged 50-70 y, men or women, body mass index (BMI) 18-30 kg/m 2, who were scheduled for ophthalmic surgery were enrolled. According to the random number table method, the patients were divided into two groups ( n=40): a propofol combined with remifentanil group (group P) and a remazolam combined with remifentanil group (group R). Anesthesia induction: group P was intravenously injected with propofol at 2 mg/kg, while group R was intravenously injected with remazolam at 0.2 mg/kg. Both groups were administered with 30 μg/kg afentanil. When the patients became unconscious, 0.2 mg/kg cisatracurium was given and laryngeal mask was inserted. Anesthesia maintenance: group P was intravenously infused with propofol at 6-10 mg·kg -1·h -1, while group R was intravenously infused with remazolam at 0.4-1.2 mg·kg -1·h -1. Both groups were intravenously infused with remifentanil at 0.1-0.2 μg·kg -1·min -1, with intravenous injection of cisatracurium in an intermittent manner. Bispectral index (BIS) value was maintained at 50-60 and hemodynamics was stable during surgery. Then, their operation time, anesthesia time, infusion volume, intraoperative dosage of remifentanil, the time to loss of consciousness, the time to the recovery of consciousness, the time of laryngeal mask removal, the length of post-anesthesia care unit (PACU) stay, the occurrence of intraoperative hypertension, hypotension, tachycardia, bradycardia, and the use of vasopressor drugs were recorded. The occurrence of injection pain, postoperative adverse reactions such as hypoxia, drowsiness, nausea and vomiting, as well as the occurrence of intraoperative awareness and remedial analgesia were recorded. Results:Compared with group P, there were no statistical differences in the time to loss of consciousness, the time to the recovery of consciousness, the time of laryngeal mask removal, and the length of PACU stay in group R ( P>0.05). Compared with group P, group R showed decreases in the incidence of hypotension and bradycardia ( P<0.05), and increases in the use of intraoperative antihypertensive agents ( P<0.05), with a reduced incidence of injection pain during anesthesia induction ( P<0.05). No intraoperative awareness occurred in the two groups, while no remedial analgesia was needed. There was no statistical difference in the incidence of postoperative adverse reactions between the two groups ( P>0.05). Conclusion:Remazolam can be used in combination with remifentanil for anesthesia in patients undergoing ophthalmic surgery in a safe and effective manner.

髋部骨折的老年患者常伴随多种合并症和并发症,麻醉及围手术期管理不当,患者病死率将大大增加.文章介绍1例高龄合并扩张型心肌病髋部骨折患者的围手术期管理经验.患者高龄、女性,髋部骨折合并冠心病、扩张型心肌病、心脏瓣膜病(二尖瓣、主动脉瓣及三尖瓣关闭不全)、肺间质纤维化、脑血管疾病史,采用神经阻滞复合Taylor's蛛网膜下腔麻醉下实施手术,患者平稳完成手术,术后恢复良好.

Objective To investigate the efficacy and safety of postoperative analgesia with low-dose esketamine in patients undergoing thoracoscopic radical resection of lung cancer. Methods Eighty patients undergoing thoracoscopic radical resection of lung cancer were equally and randomly divided into esketamine group and control group. Both two groups received anesthesia induction with intravenous injection of 0.05 mg/kg midazolam, 1.5 to 2 mg/kg propofol, 0.6 μg/kg sufentanil and 0.6 mg/kg rocuronium, and meanwhile esketamine group received intravenous injection of 0.1 mg/kg of esketamine. Both two groups received anesthesia maintenance with inhalation of 1% to 2% sevoflurane, intravenous pump of 0.1 to 0.3 μg/（kg·min） remifentanil and intermittent intravenous injection of 0.3 mg/kg rocuronium, and meanwhile esketamine group was continuously pumped with 0.12 mg/（kg·h） esketamine. For postoperative patient-controlled intravenous analgesia, esketamine group was given 50 mg oxycodone+25 mg esketamine+100 mL normal saline, and control group was given 50 mg oxycodone+100 mL normal saline. The dosage of oxycodone, the incidence of adverse reactions such as dizziness, nausea and vomiting in 48 h after operation, the numerical rating scale（NRS） scores at rest in 4, 12, 24, 48 and 72 h after operation, the NRS scores during movement in 24, 48 and 72 h after operation, the first postoperative patient-controlled analgesia time and frequency, the first out-of-bed activity time and the first food intake time were recorded in two groups. The 15-item quality of recovery（QoR-15） score was used to evaluate the recovery of patients in two groups in 24, 48 and 72 h after operation. Results The NRS score at rest in 24hpostoperatively and NRS scores during movement in 24,48and 72hpostoperatively were lower in esketamine group（3.4±1.4;5.3±1.8,4.5±1.5,3.7±1.8）than those in control group（4.6±1.4;6.5±1.2,5.6±1.7,4.7±1.8）（P＜0.05）.QoR-15scores in 24,48and 72hpostoperatively were higher in esketamine group（83.0±9.2,103.7±11.2,115.6±10.9）than those in control group（75.3±12.3,97.2±11.7,108.5±11.5）（P＜0.05）.The first use of patient-controlled analgesia was later in esketamine group [（7.1±1.3）h]than that in control group[（6.2±1.6）h]（P＜0.05）,and the first out-of-bed activity was earlier in esketamine group[（15.1±1.4）h]than that in control group[（15.9±1.7）h]（P＜0.05）.There were no significant differences between two groups in the NRS scores at rest in 4,12,48and 72hafter operation,the consumptions of oxycodone in 24and 48h after operation,the first food intake time after operation,the frequency of postoperative patient-controlled analgesia and the incidences of dizziness,nausea/vomiting and hallucination（P＞0.05）.Conclusion The application of low-dose esketamine during and after thoracoscopic radical resection of lung cancer can reduce postoperative motor pain and promote enhanced recovery after surgery without increasing the incidence of adverse reactions.

目的 血清白细胞介素-17A(IL-17A)在一些中枢神经系统疾病中具有重要作用.文中探讨术前IL-17A水平与老年膝髋关节置换术后谵妄(POD)的相关性及其预测价值.方法 连续入选自2020年12月至2022年2月在南京大学附属金陵医院行椎管内麻醉下膝髋关节置换术的老年患者122例.根据是否发生谵妄分为POD组(n=20)和NPOD组(n=102).比较2组患者一般资料及血液学指标,单因素分析筛选后采用Logistic回归模型进行多因素分析,获得POD的独立危险因素,应用ROC曲线和曲线下面积评价IL-17A和清蛋白对POD的预测价值.结果 发生POD的患者共20例,POD发生率为16.39％.单因素分析结果表明,术前ASA分级、清蛋白、预后营养指数、IL-17A水平、术后是否接受神经阻滞及术后疼痛评分组间差异有统计学意义(P<0.05).多因素Logistic回归分析表明,术前清蛋白降低(OR=0.54,95％CI:0.339～0.859)、IL-17A水平增高(OR=1.503,95％CI:1.065～2.121)是POD的独立危险因素(P<0.05).术前清蛋白和IL-17A水平对预测老年患者POD的ROC曲线下面积分别为0.847、0.795,灵敏度分别为95％、100％,特异度分别为61.8％、46.6％,均有统计学意义(P<0.01).结论 术前血清IL-17A水平增高、清蛋白水平降低与老年患者膝髋关节置换术后并发谵妄相关,并具有较高的预测价值.

国际疼痛研究协会将疼痛定义为"一种与实际或潜在的组织损伤相关的不愉快的感觉或情感体验" [1]。过去认为疼痛是一种主观感觉，在全身麻醉期间无法监测，临床医生对于镇痛水平的评估主要依靠患者心率、血压等临床征象，这种评估手段不够精确且易受混杂因素影响。随着对疼痛机制的深入研究发现，疼痛可分为主观疼痛和客观疼痛。全身麻醉期间，患者意识消失，主观疼痛消失，但客观疼痛仍然存在，因此可根据客观疼痛体征监测患者的镇痛水平。全身麻醉期间镇痛不足可致患者心率增快、血压增高、患者体动甚至发生脑血管意外；镇痛过度可致患者苏醒延迟、恶心呕吐、胃肠功能抑制和呼吸抑制等。因此全身麻醉期间对患者进行镇痛监测很有必要，期望应用最小剂量的镇痛药物达到满意的镇痛水平，加速患者康复。

自然界和生物机体中广泛存在节律,如一年四季、昼夜节律、激素分泌节律、心脏节律等.同样,日常的脑活动也有其规律性,常以节律性脑电信号即正常脑电波进行表达.常见的脑电波波形有经典的delta波、theta波、alpha波、beta波和近期研究中发现并关注的 gamma 波、ripple 波和纺锤波等.各种脑电波叠加整合后形成脑电图( electroencepha-logram, EEG) ,可反映脑功能的状态.

Objective:To investigate the effect of esketamine on the hippocampal neuron brain derived neurotrophic factor (BDNF) pathway protein expression and dendritic spine density in mice undergoing abdominal surgery.Methods:Totally, 24 C57BL/6-8 weeks old male mice were randomly divided into control group, abdominal surgery in isoflurane anesthesia group (Iso) and abdominal surgery in esketamine anesthesia group (Esk). On the third day after surgery the mice hippocampal neurons were extracted to be stained by Golgi-Cox for dendritic spine calculation. The BDNF pathway protein expression level of the neurons was detected by Western blotting. One-way analysis of variance (ANOVA) was used for comparison between groups, and SNK- q test was used for further pairwise comparison. Results:The BDNF relative protein levels in control group, Iso group and Esk group were respectively 0.95±0.25, 0.31±0.16 and 0.46±0.15, and the pTrkB/TrkB level in control group, Iso group and Esk group were respectively 1.39±0.15, 0.42±0.11 and 0.43±0.10. The differences were statistically significant ( F=14.56, 20.01, all P<0.05). The BDNF expression and the TrkB phosphorylation level in hippocampal neurons were lower in Iso group and Esk group than in control group (all P<0.05), but there was no significant difference between Iso and Esk groups ( P>0.05). The dendritic spine density in hippocampal neurons in control group, Iso group and Esk group was respectively (8.93±2.01), (4.11±1.64), (4.08±1.72)/10 μm, and mushroom-type spines in the hippocampal neurons in three groups were respectively (5.03±1.67), (2.02±0.88), (2.77±1.16)/10 μm. There was significant difference ( F=13.49, 22.16, all P<0.05). The dendritic spine and mushroom spine density in hippocampal neurons were both thicker in control group than in Iso group and Esk group (all P<0.05), but there was significant difference between the Iso and the Esk groups ( P>0.05). Conclusion:Esketamine with abdominal surgery decreases the hippocampal neuron BDNF expression and TrkB phosphorylation level and dendritic spine density in mice 3 days after abdominal surgery.

目的 探讨舒更葡糖钠对老年患者腹腔镜结直肠癌根治术后早期肺功能的影响.方法 选择择期行腹腔镜结直肠癌根治术的老年患者60例,男32例,女28例,年龄65～80岁,BMI 18～28 kg/m2,ASAⅠ—Ⅲ级.采用随机数字表法分为两组:舒更葡糖钠组(S组)和新斯的明+阿托品组(NA组),每组30例.术毕进入PACU后,当四个成串刺激(TOF)计数为2时,S组给予舒更葡糖钠2 mg/kg,NA组给予等容积的新斯的明0.02 mg/kg+阿托品0.01 mg/kg,当TOF比值(TOFr)≥0.9时拔除气管导管.记录手术时间、麻醉时间、术中肌松药用量、末次肌松至手术结束时间、手术结束至拔管时间、拮抗后TOFr≥0.9的时间、PACU停留时间、术后住院时间.记录术前、拔管后30 min及拔管后24 h用力肺活量(FVC)、第一秒用力呼气量(FEVl)及第一秒用力呼气量占所有呼气量的比例(FEV1/FVC).记录低氧血症、上呼吸道阻塞、术后肺炎、肺不张、胸腔积液、气胸等肺部并发症发生情况以及术后不良反应发生情况.结果 两组手术时间、麻醉时间、术中肌松药用量、末次肌松至手术结束时间及术后住院时间差异无统计学意义.S组手术结束至拔管时间、TOFr≥0.9的时间及PACU停留时间明显短于NA组(P<0.05).两组术前及拔管后30 min、24 h FVC、FEV1及FEV1/FVC差异无统计学意义.两组术后肺部并发症及不良反应发生率差异无统计学意义.结论 舒更葡糖钠可快速拮抗术后肌松残留,但并未改善老年患者腹腔镜结直肠癌根治术后早期肺功能及降低术后肺部并发症发生率.

Objective:To evaluate the effects of sugammadex on the quality of recovery after laparoscopic bariatric surgery in severely obese patients.Methods:One hundred and eighty patients, aged 18-65 yr, with body mass index ≥ 40 kg/m 2, undergoing elective laparoscopic bariatric surgery, of American Society of Anesthesiologists physical status Ⅲ, were enrolled and divided into 2 groups ( n=90 each) by the random number table method: sugammadex group (S group) and neostigmine group (N group). Before anesthesia, bilateral T 6 and T 9 paravertebral nerve blocks were performed, and 0.33% ropivacaine 15 ml was injected on each side.When the reappearance of T 2 was monitored under train-of-four (TOF) stimulation after the end of surgery, and sugammadex 2 mg/kg was intravenously injected in S group, and neostigmine 0.04 mg/kg and atropine 0.02 mg/kg were intravenously injected in N group.After the patient was transferred to the general ward, flurbiprofen axetil 50 mg was injected intravenously every 12 h, and oxycodone and flurbiprofen axetil were used for patient-controlled intravenous analgesia at the same time.When the numerical rating scale (NRS) score ≥4 and the analgesic pump was ineffective, bilateral T 7 paravertebral nerve block was performed for rescue analgesia, and 0.33% ropivacaine 15 ml was injected on each side.The postoperative quality of recovery was assessed by the 15-item Quality-of-Recovery scale before operation and at 24 h after operation.The TOF ratio ≥ 0.9 and extubation time were recorded.The SpO 2 at the time of transfer to post-anesthesia care unit (PACU), the lowest SpO 2 and occurrence of SpO 2 < 92% during PACU were recorded.The occurrence of residual muscle relaxation and Ramsay sedation score were recorded at 30 min after entering PACU.The time of PACU stay, time to the first off-bed activity and length of hospital stay were recorded.The cumulative consumption of oxycodone, requirement for rescue analgesia, dizziness, nausea and vomiting, hypoxemia, and pulmonary complications were recorded within 48 h after operation. Results:There were no significant differences in the total score of 15-item Quality-of-Recovery scale before surgery and at 24 h after surgery, cumulative consumption of oxycodone within 48 h after surgery, rate of rescue analgesia, and incidence of dizziness, nausea and vomiting, hypoxemia and pulmonary complications between the two groups ( P>0.05). Compared with N group, the scores of the three recovery indicators (feel energized with enough rest, engagement in work or family activities, and tension and anxiety) were significanatly increased, time to TOF ratio ≥ 0.9, extubation time, time of PACU stay, time to the first off-bed activity and length of hospital stay were shortened, and the incidence of residual muscle relaxation was decreased in S group ( P<0.05). Conclusions:Antagonizing residual muscle relaxation with sugammadex is helpful for the recovery of severely obese patients after laparoscopic bariatric surgery.

目的 观察Trendelenburg体位(T位)达芬奇机器人辅助腹腔镜宫颈癌根治术中应用不同剂量艾司氯胺酮维持麻醉时颅内压变化,探讨艾司氯胺酮应用的安全性.方法 择期全身麻醉下行达芬奇机器人辅助腹腔镜宫颈癌根治术患者60例,随机分为低剂量组、高剂量组和对照组各20例.3组麻醉诱导依次静脉注射丙泊酚2～4 mg/kg、舒芬太尼0.3～0.4 μg/kg、罗库溴铵0.6 mg/kg;麻醉维持采用静脉泵注丙泊酚3～8 mg/(kg·h)、瑞芬太尼0.1～0.2 μg/(kg·min),间断给予罗库溴铵维持肌肉松弛.低剂量组、高剂量组分别静脉泵注艾司氯胺酮0.125、0.25 mg/(kg·h)至手术结束,对照组静脉泵注等量生理盐水至手术结束.分别于麻醉诱导前即刻(T1)及T位后3 min(T2)、30 min(T3)、60min(T4)、120 min(T5)、手术结束恢复平卧位后(T6)测定3组平均动脉压、心率、局部脑氧饱和度及视神经鞘直径(optic nerve sheath diameter,ONSD);记录围术期恶心呕吐、术后谵妄、苏醒延迟等不良事件发生情况.结果 3组年龄、体质量指数、合并高血压比率、手术时间、丙泊酚诱导剂量、舒芬太尼诱导剂量、丙泊酚维持剂量、围术期不良事件发生率比较差异均无统计学意义(P＞0.05).低剂量组、高剂量组瑞芬太尼维持剂量[(1 100±54)、(1 070±85)μg]均少于对照组[(1 350±93)μg](P＜0.05),低剂量组与高剂量组比较差异无统计学意义(P＞0.05).低剂量组、高剂量组和对照组 T2[(5.06±0.22)、(5.21±0.18)、(5.03±0.20)mm]、T3[(4.80±1.10)、(5.09±0.21)、(5.09±0.13)mm]、T4[(5.25±0.14)、(4.98±0.22)、(5.14±0.16)mm]、T5[(4.97±0.23)、(4.87±0.27)、(5.13±0.19)mm]时 ONSD 均大于 T1时[(4.73±0.17)、(4.63±0.15)、(4.61±0.24)mm](P＜0.05),T6 时 ONSD[(4.64±0.20)、(4.61±0.21)、(4.60±0.22)mm]与T1时比较差异均无统计学意义(P＞0.05);3组各时间点ONSD组间两两比较差异均无统计学意义(P＞0.05);3组不同时间点及组间平均动脉压、局部脑氧饱和度、心率比较差异均无统计学意义(P＞0.05).结论 T位达芬奇机器人辅助腹腔镜宫颈癌根治术中静脉泵注0.125、0.25 mg/(kg·h)艾司氯胺酮均可维持血流动力学稳定,减少瑞芬太尼用量,且不增加患者颅内压,具有较高的安全性.

目的 探索利用升高透明平台法建立动物焦虑行为的效果和咪达唑仑对减轻利用升高透明平台法诱导的小鼠焦虑行为的作用.方法 雄性C57BL/6J小鼠39只,2月龄,体重20～24 g.将小鼠随机分为三组:对照组(C组)、升高平台应激组(E组)和升高平台应激+咪达唑仑组(EM组),每组13只.C组正常饲养;E组每天接受2次(每次持续3 min)升高透明平台应激,连续1周;EM组小鼠除接受与E组相同的升高透明平台应激外,于建模结束后第1天和第3天的行为学测试前30 min腹腔注射咪达唑仑0.5 mg/kg.建模结束后,采用旷场实验与新环境进食抑制实验检测小鼠进入旷场中心区次数、中心区停留时间、中心区运动距离和进食潜伏期.采用ELISA法检测小鼠血清皮质酮(Cor)浓度及海马组织中γ?氨基丁酸(GABA)浓度.结果 与C组比较,E组中心区进入次数明显减少(P<0.05)、中心区停留时间和中心区运动距离明显缩短(P<0.05),进食潜伏期明显延长(P<0.05),血清Cor浓度明显升高(P<0.05),海马组织GABA浓度明显降低(P<0.05).与E组比较,EM组中心区进入次数明显增加(P<0.05),中心区时间明显延长(P<0.05),进食潜伏期明显缩短(P<0.05),血清Cor浓度明显降低(P<0.05),海马组织中GABA浓度明显升高(P<0.05).结论 升高透明平台应激可诱导小鼠产生焦虑样行为,咪达唑仑可改善小鼠焦虑样行为,降低血清Cor浓度,升高海马组织GABA浓度.

Objective:To evaluate the effect of propofol on proliferation, invasion and migration of human melanoma cells and role of cyclooxygenase-2 (COX-2)/prostaglandin E2 (PGE2)/matrix metalloproteinase (MMP) signaling pathway.Methods:SKMEL-5 cells were cultured in vitro and divided into 4 groups ( n=36 each) using the random number table method: control group (group C), propofol group (group P), COX-2 overexpression group (group COX-2), and COX-2 overexpression plus propofol group (group COX-2+ P). Propofol at the final concentration of 60 μmol/L was added in group P. The COX-2 overexpression plasmid pcDNA3.1-COX-2 was transfected into SKMEL-5 cells in group COX-2 and group COX-2+ P, and propofol at the final concentration of 60 μmol/L was added in group COX-2+ P.After incubation for 48 h, the cell proliferation rate was determined by CCK-8 method, the cell invasion and migration ability was determined by Transwell assay, the expression of COX-2 in cells was detected by Western blot, the expression of COX-2 mRNA in cells was detected by quantitative real-time polymerase chain reaction, and the concentrations of serum PGE2, MMP-2 and MMP-9 were determined by enzyme-linked immunosorbent assay. Results:Compared with group C, the cell proliferation rate was significantly decreased, the number of cell invasion and migration was decreased, the expression of COX-2 protein and mRNA was down-regulated, and the concentrations of PGE2, MMP-2 and MMP-9 in the supernatant were decreased in group P, and the cell proliferation rate was significantly increased, and the number of cell invasion and migration was increased, the expression of COX-2 protein and mRNA was up-regulated, and the concentrations of PGE2, MMP-2 and MMP-9 in the supernatant were increased in group COX-2 ( P<0.05). Compared with group P, the cell proliferation rate was significantly increased, and the number of cell invasion and migration was increased, the expression of COX-2 protein and mRNA was up-regulated, and the concentrations of PGE2, MMP-2 and MMP-9 in the supernatant were increased in group COX-2+ P ( P<0.05). Conclusions:Propofol can inhibit the proliferation, invasion and migration of human melanoma cells, and the mechanism may be related to inhibition of the COX-2/PGE2/MMP signaling pathway.

患者,女,29岁,156 cm,71. 5 kg,因"停经38+5周,不规律下腹痛8h"入院.初产,既往无高血压、糖尿病、心脏病疾病史,妊娠期血压、血糖均正常.查体:HR 80次/分, RR 20次/分,BP 110/70 mmHg.心电图、血常规、凝血功能、肝肾功能、电解质均正常.患者临产后在子宫颈口扩张2 cm时行分娩镇痛,经L2-3间隙硬膜外穿刺过程中注射器负压试验阴性,继续进针阻力突然消失,观察注射器内有脑脊液流出,回抽确认后迅速退针,经L1-2硬膜外再次穿刺置管顺利,予试验量0. 1％罗哌卡因5 ml,患者诉双下肢麻木,测麻醉平面达T6 平面,随后转手术室行剖宫产术,手术顺利.术后为预防硬脊膜穿破后头痛( post dural puncture headache, PDPH) ,建议去枕平卧、每日静脉输注复方乳酸钠2500 ml.

Objective:To evaluate the optimization efficacy of low-dose esketamine combined with propofol in the patients with major depressive disorder undergoing modified electroconvulsive therapy (MECT).Methods:Fifty-six American Society of Anesthesiologists physical statusⅠor Ⅱ patients, aged 18-64 yr, scheduled for MECT for the first time, were assigned into esketamine plus propofol group (group EP, n=28) and propofol group (group P, n=28) according to a ratio of 1∶1 by the random number table method.Esketamine 0.25 mg/kg was intravenously injected before anesthesia induction in group EP, while the equal volume of normal saline was given instead in group P. Propofol and succinylcholine were then intravenously injected to perform MECT in two groups.The primary outcomes were the remission rate and response rate, and the secondary outcomes included the number of MECT required for response and remission, the seizure duration, energy inhibition index and consumption of propofol for each MECT, and the occurrence of therapy-related adverse reactions and relapse. Results:Compared with group P, the remission rate and response rate were significantly increased, and the number of MECT required for response and remission was decreased, the seizure duration was prolonged, and energy inhibition index was increased, the consumption of propofol was reduced ( P<0.05), and no significant change was found in the incidence of therapy-related adverse reactions and relapse in group EP ( P>0.05). Conclusions:Low-dose esketamine combined with propofol can enhance the efficacy of MECT and shorten the course of therapy without increasing therapy-related adverse reactions in the patients with major depression.

目的 观察诱导期使用小剂量艾司氯胺酮对老年胃肠道手术患者全麻诱导期血流动力学和术后谵妄的影响。方法 选择全麻行胃肠道手术患者80例，年龄≥60岁，ASA分级Ⅰ或Ⅱ级，术前简易智能状态量表评分＞23分。采用随机数字表法分为2组（n=40）：艾司氯胺酮组和对照组。麻醉诱导前艾司氯胺酮组静脉注射艾司氯胺酮0.25mg/kg，对照组静脉注射等容量生理盐水。随后静脉注射咪达唑仑、依托咪酯、舒芬太尼和顺阿曲库铵诱导，静脉泵注丙泊酚、瑞芬太尼，间断注射顺阿曲库铵维持麻醉。比较两组入室5min后（T0）、插管前（T1）、插管后即刻（T2）、插管后3min（T3）的心率、平均动脉压，比较谵妄发生率、术后疼痛评分（NRS）和术后其他不良反应发生情况。结果 两组T0时的心率、平均动脉压比较差异无统计学意义（P＞0.05），两组T2时的心率及T3时的平均动脉压比较，差异有统计学意义（P＜0.05）。艾司氯胺酮组的心率、平均动脉压在各时间点无明显变化（P＞0.05）。对照组心率和平均动脉压在T1时较T0降低，T3时较T2时降低，T2时的心率较T1时升高（P＜0.05）。艾司氯胺酮组有2例患者出现术后谵妄，低于对照组（8例）（P＜0.05）。两组NRS评分和术后其他不良反应发生率差异均无统计学意义（P＞0.05）。结论 诱导期应用小剂量艾司氯胺酮可以减少老年手术患者麻醉诱导期血流动力学波动，降低术后谵妄的发生率。

急性术后疼痛(APP)是患者受到手术刺激后出现的一系列生理、心理及行为反应等,主要集中在术后24～72 h,常持续4～6 d.APP严重影响手术预后,而导致患者APP治疗不充分的原因较多,因此,APP的管理重点在于对疼痛的评估和预防,充分理解和掌握APP危险因素和疼痛程度预测方法对于APP的管理十分必要.APP的危险因素包括人口社会学因素、心理因素、术前疼痛及阿片类药物的使用、手术、麻醉相关因素等.APP程度预测方法包括镇痛监测指标、局部浸润麻醉疼痛评分、外周静脉针留置疼痛评分、定量感觉检查、疼痛敏感度问卷、脑电图等.全文主要就其在急性术后疼痛危险因素和疼痛程度预测方法的进展进行综述,为临床应用提供参考.