颈动脉内膜斑块切除术(carotid endarterectomy,CEA)是治疗颈动脉狭窄、防止脑卒中、降低死亡率的有效方法.60多年来,CEA手术方式不断成熟,但其围术期麻醉管理仍存在着众多值得探讨的热点.CEA围术期风险性极高,因此恰当的围术期麻醉管理是保证围术期安全的重要因素.本文对CEA围术期麻醉管理进展做一综述,以期为临床工作者提供参考.

目的 探讨抗苗勒管激素(AMH)联合抑制素B(INHB)在高龄妇女卵巢储备功能评估中的应用价值,为高龄妇女卵巢储备功能的评估提供理论依据.方法 选取2015年1月-2016年5月在该院进行孕前检查的高龄妇女105例为研究对象,按卵巢储备功能分为正常组35例、卵巢功能减退(DOR)组38例和卵巢早衰(POF)组32例,其中正常组按照1年内是否成功受孕分为妊娠组和非妊娠组.统计3组受试者基础内分泌激素及血清AMH和INHB水平的差异并进行相关性分析,统计妊娠组和非妊娠组受试前卵巢储备功能相关激素水平的差异.结果 3组受试者血清AMH和INHB水平比较差异有统计学意义(P＜0.05);受试者窦卵泡计数(AFC)和雌二醇(E2)与AMH和INHB水平均呈正相关关系(P＜0.05);卵泡刺激素(FSH)和黄体生成素(LH)与AMH和INHB水平均呈负相关关系(P＜0.05);而受试者血清AMH和INHB水平呈正相关关系(r=0.582,P=0.000).正常组成功妊娠率为68.57％,妊娠组和非妊娠组AFC和血清FSH、LH、E2水平差异无统计学意义(P＞0.05),而妊娠组AMH和INHB水平均明显高于非妊娠组,差异均有统计学意义(P＜0.05).结论 高龄妇女血清AMH和IN-HB水平是预测卵巢储备功能的有效指标,其与AFC及血清FSH、LH和E2等激素水平具有明显的相关性,采取AMH和INHB联合检测能更准确的评估妇女卵巢储备功能.

目的:探讨依托咪酯联合舒芬太尼静脉麻醉下经阴道取卵术的镇痛效果及对体外授精-胚胎移植(IVF-ET)妊娠结局的影响.方法:132例IVF-ET患者随机分为依托咪酯组(E组)和丙泊酚组(P组),E组静脉注射依托咪酯0.2 mg/kg及舒芬太尼0.05 μg/kg麻醉,P组静脉注射丙泊酚2.0 mg/kg及舒芬太尼0.05 μg/kg麻醉.观察两组麻醉效果、安全性及妊娠结果.结果:所有手术过程顺利.两组授精率、卵裂率、优质胚胎率、临床妊娠率、早期流产率及妊娠率均无统计学差异(P＞0.05).与P组相比,E组血流动力学稳定,呼吸抑制发生率低,更少发生术后恶心呕吐(P＜0.05).结论:依托咪酯联合舒芬太尼静脉麻醉下行经阴道取卵术镇痛效果显著,对呼吸抑制较轻,而且不影响IVF-ET结果.

目的:比较舒芬太尼和芬太尼应用于婴幼儿先天性心脏病手术麻醉的临床效果及安全性.方法:60例择期拟行房、室缺修补术婴幼儿,随机分为舒芬太尼组(A组)和芬太尼组(B组),每组30例.比较两组患儿不同时间点的血流动力学改变、应激反应指标以及麻醉恢复时间.结果:两组患儿脑电双频指数(bispectral index,BIS)、体外循环(cardio pulmonarybypass,CPB)时间及手术时间无统计学差异(P＞0.05);诱导后两组患儿HR、MAP均下降且B组下降幅度明显(P＜0.05);去甲肾上腺素、血糖、血浆皮质醇均升高,B组升高显著(P＜0.05).A组清醒时间、拔管时间及ICU停留时间均短于B组(P＜0.05).结论:舒芬太尼复合七氟醚能有效抑制血浆儿茶酚胺的释放,应用于婴幼儿心血管手术的麻醉具有更好的循环稳定性.

目的：评价腰丛-坐骨神经阻滞在老年患者髋部骨折内固定术中的应用价值。方法老年股骨干骨折及转子间骨折患者112例，按照数字随机法分为腰丛-坐骨神经阻滞组（L 组）与连续硬膜外阻滞组（E 组），记录两组麻醉前，麻醉后即刻，麻醉后10、15、20、25、30 min 收缩压（SBP）、舒张压（DBP）、心率（HR）、血氧饱和度（SpO2），并在各时间点对其进行感觉、运动功能评分，记录术中麻黄碱使用情况。结果麻醉后即刻、麻醉后10 min，L 组的生命体征平稳，与 E 组比较有统计学差异（P ﹤0.05）。E 组的 HR、BP 变化较大，麻醉后即刻心率增快、血压升高且与麻醉前相比有统计学差异（P ﹤0.05）。L、E 两组在运动评分的比较中差别较大（P ﹤0.05）。在麻醉后即刻、麻醉后10 min 和20 min 三时间点，L 组感觉评分≤2分的患者明显大于 E 组，有统计学意义（P ﹤0.05）。L 组麻黄碱用量低于 E 组，两组比较差异有统计学意义（P ﹤0.05）。结论腰丛-坐骨神经阻滞用于老年患者髋部骨折内固定术起效快、安全，值得临床推广应用。

Objective To evaluate the role of haeme oxygenase-1 (HO-1) in remote limb ischemic preconditioning (RLIP)-induced attenuation of lung ischemia-reperfusion (I/R) injury in rabbits.Methods Twenty-four Japanese White Rabbits,aged 4-5 months,weighing 2.0-2.5 kg,were randomly divided into 4 groups (n =6 each) using a random number table:sham operation group (S group),I/R group,RLIP group and zinc protoporphyrin (ZnPP,an inhibitor of HO-1) plus RLIP group (ZnPP + RLIP group).Lung I/R was produced by 60 min occlusion of the left lung hilum followed by 180 min of reperfusion in I/R,RLIP and ZnPP + RLIP groups.RLIP and ZnPP + RLIP groups received 3 cycles of 10 min ischemia followed by 10 min reperfusion in the bilateral hind limbs immediately before occlusion of the left lung hilum.In ZnPP + RLIP group,ZnPP 10 μmol/kg was injected intravenously 10 min prior to hind limb ischemia and the rest of the procedures were similar to those previously described in RLIP group.At the end of reperfusion,arterial blood samples were collected for blood gas analysis.The animals were then sacrificed and pulmonary specimens were obtained for microscopic examination of the pathological changes which were scored (lung injury score,LIS) and for determination of wet/dry lung weight ratio (W/D ratio),myleoperoxidase (MPO) activity,malondialdehyde (MDA) content and expression and activity of HO-1 in the lung tissues.Results Compared with group S,PaO2 was significantly decreased,and LIS,W/D ratio,MPO activity,MDA content,and HO-1 expression and activity were increased in I/R group (P ＜ 0.01).Compared with I/R group,PaO2 and HO-1 expression and activity were significantly increased,and LIS,W/D ratio,MPO activity and MDA content were decreased in RLIP group (P ＜ 0.01).Compared with RLIP group,PaO2 and HO-1 expression and activity were significantly decreased,and LIS,W/D ratio,MPO activity and MDA content were increased in ZnPP + RLIP group (P ＜ 0.01).Conclusion RLIP up-regulates HO-1 expression and enhances HO-1 activity,thus reducing lung I/R injury in rabbits.

Objective To evaluate the effect of exogenous apelin-13 on cerebral ischemia-reperfusion (I/R) injury in rats .Methods Fifty-eight male Sprague-Dawley rats ,aged 6-8 weeks ,weighing 250-320 g ,were randomly divided into 7 groups using a random number table :sham operation group (group S , n=10 ) ,I/R group (n=10) ,dimethyl sulfoxide group (group D , n=6) ,apelin-13 (1 nmol) + I/R group (group A1 , n=6) , apelin-13 (5 nmol ) + I/R group (group A5 , n=10 ) ,apelin-13 (5 nmol ) + LY294002 (PI3K inhibitor ) group (group A5 +LY , n=10) ,and apelin-13 (10 nmol) + I/R group (group A10 , n=6) .Focal cerebral ischemia was produced by introducing a nylon intraluminal suture into the cervical internal carotid artery and advancing it intracranially to block blood flow into the middle cerebral artery according to the method described by Longa et al . The corresponding dose of apelin-13 ,apelin-13+ LY294002 10 nmol ,or the equal volume of dimethyl sulfoxide was injected into the lateral cerebral ventricle in each group at 30 min before cerebral ischemia .Neurological function was assessed and scored using neurologic behavior scores (NBSs) at 24 and 72 h of reperfusion .The rats were sacrificed at 24 h of reperfusion and brains removed for detection of cell apoptosis and expression of phosphorylated-glycogen synthase kinase 3 beta (pGSK-3β) .The rats were sacrificed at 72 h of reperfusion to measure the cerebral infarct size .Results Compared with S group ,NBSs at each time point were significantly decreased ,the cerebral infarct size was enlarged ,the number of apoptotic neurons was increased ,and pGSK-3βexpression was up-regulated in group I/R ( P<0.05 or 0.01) .Compared with I/R group ,NBSs were significantly increased ,and the cerebral infarct size was decreased in A 5 and A10 groups ,and the number of apoptotic neurons was reduced ,and pGSK-3βexpression was up-regulated in group A5 ( P<0.05) .NBSs were significantly lower , the cerebral infarct size was larger ,and pGSK-3βexpression was lower in A5+LY group than in A5 group ( P<0.05) .Conclusion Exogenous Apelin-13 can attenuate cerebral I/R injury in rats and activation of the PI3K signaling pathway and enhanced inactivation of GSK-3βare involved in the mechanism .

Objective To investigate the effects of fluid resuscitation on pulmonic morphology of dogs with hemorrhagic shock at initial stage of ascending high altitudes.Methods 13 mongrel dogs were randomly divided into 3 groups after arriving at high altitudes.The control group received no treatment after fall in hemorrhagic shock(n=3),the LR group(n=5) was treated by intravenous transfusion of balanced solution in 1.5 times volume of lost blood,and the HAES group(n=5) was given HAES steril in equal volume.Both groups sustained transfusion of balanced solution at 5 ml/(kg·h) after resuscitation.All animals were sacrificed by exsanguination 48 h after resuscitation and the morphological changes of lungs were pathologically observed.Results The dogs in control group were all dead 2 hours after shock and were not included in statistical analysis.The lung weight/body weight index and semi-quantitative scores of histopathological changes in LR group and HAES group were(0.78±0.14)%,(1.25±0.38)and(1.03±0.27)%,(3.85±0.48),and there were significant difference in two groups(P<0.05).The microstructure of lung tissues were observed under the light microscope,the results showed an apparent interstitial pulmonary edema,and alveolar pulmonary edema in HAES group.Conclusion The dogs with hemorrhagic shock at initial stage of ascending high altitudes must be treated with fluid resuscitation,otherwise,the death rate would be 100%.1.5 times transfusion of balanced solution can prevent pulmonic edema.Transfusion of equal volume of HAES steril 200/0.5 failed in preventing pulmonic edema.

Objective To investigate effects of adenosine on early postoperative cognitive dysfunction(POCD) in elderly patients undergoing cardiac valve replacement surgery.Methods Sixty patients older than 60 years of age,scheduled for selective cardiac operation were selected for this study.Patients were randomly divided into two groups:control and adenosine groups.Adenosine disodium triphosphate(2 mmol/L)was added into heart arresting solution in adenosine group.Neuropsychological testing was performed with neurocognitive test battery consists of MMSE,DSpT,DSyT,TMT and SMT at pre-operation,7 days and 2 weeks after surgery.Results 57 patients completed all tests.POCD was present in 12(40.0%)patients in control group,7(23.3%) patients in adenosine group at 7 days after surgery.The incidence of POCD in adenosine group at 7 days after surgery was lower than that in control group(P<0.05).However,the incidence of POCD was not different at 2 weeks after surgery.Conclusion Adenosine could reduce the incidence of POCD in elderly patients undergoing cardiac valve replacement surgery within 7 days.

Objective To study the strategies in assessing early postoperative cognitive dysfunction(POCD) in elderly patients underwent non-cardiac surgery with total intravenous anesthesia(TIVA) or intravenous-inhalation combined anaesthesia.Methods 142 patients who were older than 65 years were enrolled in this study.Patients were divided into two groups.Methods of general anaesthesia include total intravenous anesthesia and intravenous-inhalation combined anaesthesia.Cognitive function was evaluated by mini-mental-status examination(MMES),digit span test,digit symbol substitution test,trail making test and comprehension memory subtest.Group A was tested with MMSE on one day before surgery,on the 1st,3rd,5th and 7th postoperative day.Group B was tested with five neurocognitive test batteries preoperatively and on the 7th day postoperatively.Results MMSE scores were increasing with test times and the incidence of POCD was declined accordingly.The incidence of POCD in patients with TIVA had a lower tendency than that with intravenous-inhalation combined anaesthesia on 7th day postoperatively;however the difference was no statistical significance.Conclusion The five neurocognitive test batteries might be more effective than MMSE in evaluating early POCD in elderly patients.There were no statistical difference in the incidences of POCD between TIVA and intravenous-inhalation combined anaesthesia.

Objective To study the relation between female gonad toxicity of methoxychlor on rats and the expression of estrogen receptor(ER) in uterus and ovary.Metheds 40 SD female rats were randomly divided into 4 groups base on body weight and were injected subcutaneously by the 4 dose levels(o,16,32,64 mg/kg body weight) for 20 days.Vaginal smears of rats were taken to determine estrous cycle.The rats were sacrificed on the day of estrus stage.Body weights,estrus stage,organ weights and organ coefficients of ovary were observed.Serum follicle stimulating hormone(FSH),leteinizing hormone(LH),estradiol(E2) and progestereone(P) were detected with the radio immunoassays.Results The period of estrus cycle of intermediate and high concentration groups were longer than normal group(P<0.05).The organ coefficients of uterus,ovary and the positive arte of ER of experiment groups was similar to normal group(P>0.05).Conclusion MXC in experimental dose may induce the disorder of hypothalamic-pituitary-ovarian axis and decrease the expression level of FSH,however,this dose can not change the expression level of ER secreted from ovarian and uterus,and increase the toxicities of female gonad.

Objective: To determine the half-effective concentration(EC50) of ropivacaine in nerve stimulator-guided supraclavicular brachial nerve block.Methods: Surpaclavicular brachial nerve block guided by nerve stimulator was performed in 50 patients with ASAⅠtoⅡ requiring scheduled elective upper-limb surgery.Each participant received 30 ml bolus of ropivacaine,and the concentration of ropivacaine was given by the response of the previous patient to a higher or lower concentration using double-blind,up-and-down sequential allocation.The initial concentration of ropivacaine was 0.30%,and the variety of two close concentrations was 0.025%.The anesthetic efficacy was assessed with visual analogue scale(VAS) within 30 min after anesthesia,and the effectiveness was defined as having a VAS≤4.The EC50 was obtained by probit analysis.Results: Among the 50 patients,one was excluded from the study because of uncertain anesthetic efficacy.The EC50 of ropivacaine in nerve stimulator-guided supraclavicular brachial nerve block was 0.295%,and 95% confidence interval was 0.276-0.316%.Conclusion: The EC50 of ropivacaine in nerve stimulator-guided supraclavicular brachial nerve block is 0.295%.The possible effects of assisted drug during operation needed further study.

OBJECTIVE:To study the effects of limb ischemia preconditioning on pulmonary free radicals and cytokine levels during lung ischemia-reperfusion injury in rabbits. METHODS:Eighteen healthy rabbits were randomly divided into three groups: control group (group C, n = 6), ischemia/reperfusion group (group I/R, n = 6), limb ischemia preconditioning group (group L, n = 6). At the end of experiments, the wet to dry-weight ratio (W/D), activities of superoxide dismutase (SOD) and myeloperoxidase (MPO), levels of malondialdehyde (MDA) and the contents of cytokines (TNF-α, IL-6, IL-8 and IL-10) were determined in lung tissues. Protein levels of bronchoalveolar lavage fluid and serum were measured to calculate the lung permeability index. Pathologic changes of lung tissues were also observed. RESULTS:Compared to the group I/R, the lung tissue W/D ratio, MPO activity, lung permeability index, MDA and the cytokines (TNF-α, IL-6 and IL-8) levels were significantly decreased in group L (P < 0.05), while the SOD activity (P < 0.05) and IL-10 contents were significantly increased (P < 0.01). There was no statistical difference in the changes of the above parameters between group L and group C (P > 0.05). The morphologic damages were significantly reduced in group L than that in group I/R. CONCLUSION:Limb ischemia preconditioning has protective effect against lung ischemia-reperfusion injury, which may at least in part through inhibiting the release of oxygen-derived free radicals and pro-inflammatory cytokines (TNF-α, IL-6, IL-8) and increasing the production of anti-inflammatory cytokine IL-10.

需手术治疗的风湿性心脏瓣膜病患者又合并有冠心病,需同期进行瓣膜置换术和冠脉搭桥术方可达到良好的治疗效果,但此类患者往往心功能较差,麻醉危险性大.近年来我院共实施此类手术18例,现报告如下.

AIM: To observe the effect of electroacupuncture(EA) preconditioning on cognitive dysfunction in patients undergoing heart valve replacement surgery and coronary artery bypass grafting(CABG) with cardiopulmonary bypass under general anesthesia.METHODS: One hundred and six patients(49 males,57 females) were randomly allocated to EA preconditioning group and control group.EA preconditioning group was treated at bilateral Neiguan(PC 6),Lieque(LU 7) and Yunmen(LU 2) with electrical stimulation(5-30 Hz,2.34-6.24 mA,30 min) for 5 consecutive days before heart valve replacement surgery and CABG.Before operation and 7 days and 14 days after operation,all patients were required to undergo a battery of five neuropsychological tests including mini-mental status examination,digit span test,digit symbol test,trial-making test and short-story memory test.RESULTS: A total of 75 patients completed the tests(38 in EA group and 37 in control group).No significant differences were found in age,gender,height,weight and educational level between groups.The incidence of postoperative cognitive dysfunction in EA group and control group was 26.3% and 24.3% 7 days after operation,and 10.5% and 13.5% 14 days after operation,respectively.Statistical analysis showed no significant difference between groups.CONCLUSION: EA preconditioning has no effect on the incidence of cognitive dysfunction in patients to be treated with heart valve replacement surgery and CABG with cardiopulmonary bypass under general anesthesia.

小儿气管、支气管异物取出术麻醉现主要是γ-羟丁酸钠(γ-OH)复合氯胺酮加表麻,但其主要副作用是患儿苏醒慢,呼吸道分泌物多.而异丙酚作为一种新型的短效麻醉药应用于小儿气管异物取出,有望取代γ-羟丁酸钠.本研究旨在比较此两种麻醉方法在小儿气管异物取出术中的应用.

目的:观察和比较肌松药在小儿气管异物取出术中使用与否,判断对麻醉管理和手术操作的影响。方法:选择全麻下行气管异物取出术的患儿69例,ASAⅡ～Ⅲ级,随机分为两组:对照组(n=29,麻醉中不使用肌松药)和肌松药组(n=40,麻醉中使用肌松药)。麻醉中观察术中有无挣扎呛咳、屏气、气管痉挛、低氧血症及术后并发症(如喉头水肿、气管痉挛、呼吸困难、低氧血症等),并记录手术时间和丙泊酚用量。结果:对照组中29例患儿术中均有不同程度的挣扎及呛咳、屏气及气管痉挛、低氧血症的发生;而肌松药组40例患儿术中均没有发生以上并发症,两组差异有显著性。对照组术后发生喉头水肿和气管痉挛等引起的呼吸困难和低氧血症,发生率高于肌松药组,差异有显著性。结论:气管异物取出术中使用肌松药,可减少气管痉挛和屏气引起的低氧血症,还可以减少因患儿术中挣扎和呛咳引起的呼吸道损伤,并且减少术后并发症。

Objective:To evaluate the effect of fluid resuscitation of different volumes on DO2,VO2 and pHi after hemorrhagic shock in dogs at high altitude.Methods: A total of 18 adult dogs,first transported to the place of 3 780 meters above the sea level,were randomly divided into three groups(n = 6): group I underwent hemorrhagic shock,group II and III were infused the lactated Ringer's solution(LR) with 1.5,3 fold volume of blood loss respectively after hemorrhagic shock.The DO2I,VO2I,O2ER,pHi and PgCO2 were measured before and after blood letting,1 h after hemorrhagic shock and 20,60,120 min after fluid resuscitation,respectively.Results: To compare with the basic value,DO2I decreased 70% and VO2I decreased 60% at 1 h after the shock.The VO2I and DO2I were significantly increased after fluid resuscitation in group II and III,but the DO2I and VO2I were significantly lower in group III compared with that in group II at 2 h after fluid resuscitation(P0.05).The PgCO2 gradually increased and pHi reduced after hemorrhagic shock.PgCO2 and pHi recovered to the value before the shock at 20 min after fluid resuscitation.But the pHi was significantly lower at 60,120 min after fluid resuscitation in group II and III compared with the basic value.The pHi was significantly lower in group III compared with that in group II(P0.05).Conclusion: To improve systemic oxygen delivery and visceral perfusion,1.5 fold volume of fluid resuscitation is better than 3 fold.

Objective:To observe the protective effect of Megluming cyclic adenylate (M-cAMP) on myocardial ischemic and reperfusion injury in patients undergoing valve replacement during cardopulmonary bypass (CPB). Methods: Thirty patients with valvar heart disease undergoing valve replacement were randomly allocated into Megluming cyclic adenylate group (group A, n=15) and control group (group B, n=15) .In group A, M-cAMP 1 mg/kg was infused before induction of anesthesia, and M-AMP 1 mg/kg was continuously infused before CPB, the rest dose of M-AMP 1 mg/kg was given during CPB. In group B, 100 ml normal saline was continuously infused during operation. Arterial blood samples were taken immediately before induction of anesthesia, at 5 min after the aortic declamping, at the end of operation, and at 6, 18 h after operation. CK-MB, TNF-α, SOD and MDA were measured. Results: The activity of SOD decreased in two groups and it was much lower in control group during CPB (P0.05). The level of CK-MB, TNF-α and MDA increased in two groups with more marked elevation in control group (P0.05). Conclusion: M-cAMP can improve the activity of SOD, and decrease the production of CK-MB, TNF-α and MDA, thereby attenuating myocardial ischemic and reperfusion injury.

Objective To observe the effects of chloroprocaine on cardiovascular response to nasotracheal intubation.Methods Forty-five ASA class Ⅰ or Ⅱ patients scheduled for selective chinfacial surgery were randomly divided into three groups of intravenous lidocaine 1.5mg/kg (group L),chloroprocaine 3mg/kg (group P) and normal saline (group C).General anesthesia was induced and maintained with target-controlled infusion of propofol at an effect-site concentration of 4μg/ml nasotracheal intubation was performed at 4min after 0.1mg/kg vecuronium injection.HR and mean arterial pressure (MAP) were recorded before intubation and at 1,2,3 and 5min after intubation.The plasma concentrations of epinephrine (E) and norepinephrine (NE) were determined at the same time points.Results After intubation,HR increased significantly in all groups,which was significantly lower in group P than that in group L and C.Group P had a significant less increase in MAP than that in group C.The concentration of E was significantly lower in group P than that in group C and L,which was not at significantly different between group L and C.The concentration of NE was significantly lower in group P at 1min after intubation than that in group L and C.Conclusion Intravenous injection of chloroprocaine 3mg/kg can effectively prevent cardiovascular response to direct laryngoscopy and nasotracheal intubation during anesthesia induction with propofol.