目的 探讨新斯的明联合不同剂量舒更葡糖钠在腹腔镜胆囊切除术中逆转深度肌松的效果.方法 收集接受腹腔镜胆囊切除术患者48例,随机分为NS2组、NS1组、NS0.5组和S4组,每组12例.术中使用罗库溴铵维持深度肌松,强直刺激(PTC)=1～2,术后NS2组、NS1组及NS0.5组在PTC=1～2时静注新斯的明60 μg/kg+阿托品15 μg/kg,在四个成串刺激(TOF)=1～2时分别静脉注射舒更葡糖钠2 mg/kg、1 mg/kg、0.5 mg/kg,S4组在PTC=1～2时静注舒更葡糖钠4 mg/kg.记录使用首剂肌松拮抗药到成串刺激比(TOFr)恢复至0.9和拔除气管导管的时间;记录使用首剂肌松拮抗剂时、使用后5 min及10 min的平均动脉压和心率、麻醉恢复室(PACU)停留时间、术后肌松残余发生率和围术期不良反应发生率.结果 4组从使用首剂肌松拮抗药到TOFr恢复至0.9的时间差异有统计学意义(P＜0.05);NS2组拔管时间与S4组相近(P=0.911),明显短于其他两组(P＜0.05);4组使用肌松拮抗剂后的血压及心率变化、PACU停留时间差异均无统计学意义(均P＞0.05);4组均无术后肌松残余及围术期不良反应发生.结论 舒更葡糖钠(4 mg/kg)逆转深度肌松的恢复时间明显短于新斯的明联合小剂量的舒更葡糖钠,联合用药并不能减少舒更葡糖钠的剂量.

目的 观察椎管内麻醉前不同剂量地佐辛用于老年髋部骨折患者的镇痛、镇静效果,评价地佐辛作为麻醉前用药的有效性和安全性.方法 择期行髋部骨折内固定术的老年患者90例,随机分为3组,每组30例.入室后B、C组分别静注地佐辛3mg和5mg,A组静注等剂量生理盐水.观察各组患者入室时(T0)、给药后15min(T1)、麻醉体位摆放期(T2)的平均动脉压(MAP)、心率(HR)、呼吸(RR)、血氧饱和度(SpO2)、Ramsay镇静评分、疼痛评分(VAS),记录各组重度高血压(高血压三级)、低血压、呼吸抑制、恶心呕吐等不良情况.结果 与A组比较,T1、T2时B、C组HR、MAP、RR、疼痛评分(VAS)明显降低,痛疼程度明显降低(P<0.05);Ramsay镇静评分较高,紧张情绪明显改善(P<0.05);且C组改变程度比B组更明显(P<0.05).与A组比较,T2时B、C组重度高血压、心动过速发生率显著降低(P<0.05);但C组呼吸抑制、低血压以及恶心呕吐发生率显著高于B组(P<0.05).结论 老年髋部骨折患者椎管内麻醉前静注3mg地佐辛,能显著改善麻醉过程中的紧张情绪和疼痛程度,明显减少重度高血压发生率,血流动力学更理想,具有很好的临床参考意义.

Objective To observe the influences of 1.3 minimum alveolar concentration (MAC) sevoflurane and desflurane on continuous infusion rate of rocuronium in children undergoing surgery.Methods Sixty children undergoing surgery under general anesthesia were randomly divided into three groups consisting of 20 children each.At first all the patients adopted the target controlled infusion of propofol (plasma concentration 3-4 ag · min-1) for induction and maintenance of anesthesia,and accepted intravenous injection of 0.6 mg · kg-1 rocuronium for intubation.TOF-Watch SX monitor was used to exert a train-of-four stimulation (TOF) at ulnar nerve in wrist,then the adductor pollicis muscle appeared muscle twitch 4 times in turn which was recorded T1,T2,T3and T4 respectively.When T1 at 5％,intravenous infusion of rocuronium began and T1 was maintained at 8％-10％ all the time.The infusion rate of rocuronium was defined the initial state when T1at 8％ -10％ for 5 min (t0).Then the infusion of propofol stopped in desflurane group (treatment Ⅰ group) and sevoflurane group (treatment H group),desflurane and sevoflurane began to be inhaled respectively and maintained end-tidal concentration at 1.3 MAC.Control group continued infusion of propofol.The infusion rates of rocuronium were recorded every 10 min,which marked with t1,t2,t3,t4 respectively(by such analogy).The recovery times of muscle relaxant in three groups were recorded which including the times of T1 from 0 to 25％,T1 from 25％ to 75％ (recovery index),TOF ratio(TOFr) from 0 to 90％.Results In treatment Ⅰ group,treatment Ⅱ group and control group,the initial infusion rates of rocuronium were (9.02 ± 1.94),(9.25 ± 2.01),(9.08 ± 1.96) μg · kg-1 · min-1 respectively.The infusion rates gradually decreased in treatment Ⅰ group and treatment Ⅱ group after sevoflurane and desflurane were inhaled,which were (4.49 ± 0.98),(4.63 ± 1.12) μg · kg-1 · min-1 respectively at t7 (P ＜ 0.05),there were no obvious change in control group at each time point (P ＞ 0.05).Compared with control group,the infusion rates of treatment Ⅰ group and treatment H group decreased significantly at t1-t7 (P ＜ 0.05).Compared with treatment Ⅱ group,the infusion rates of treatment Ⅰ group decreased significantly at t1-t5 (P ＜ 0.05).In treatment Ⅰ group,treatment H group and control group,the time of T1 from 0 to 25％ was (16.65 ± 10.96),(24.30 ± 2.35),(18.25 ± 11.31) min;the time of T1 from 25％ to 75％ (recovery index) were (7.40 ± 2.54),(14.11 ± 3.07),(8.55 ±4.60) min;the time of TOFr from 0 to 90％ were (39.58 ±4.07),(53.05 ±4.12),(40.72 ±5.85) min.Compared with control group,the recovery time of muscle relaxant had no significant different in treatment Ⅱ group (P ＞ 0.05).Compared with treatment Ⅱ group,the recovery time of muscle relaxant had significant difference in treatment Ⅰ group (P ＜ 0.05).There were no serious adverse drug reaction,the incidence of adverse drug reaction no statistical differences in three groups (P ＞ 0.05).Conclusion The 1.3 MAC sevoflurane and desflurane can significantly reduce continuous infusion rate of rocuronium in children,in a certain period of time the effect of desflurane is stronger than sevoflurane,and donot effect muscle relaxant recover time.

目的 观察吸入1.3倍最低有效肺泡浓度(MAC)七氟烷和地氟烷麻醉下对老年患者术中罗库溴铵持续输注速率的影响.方法 全麻下行择期手术的老年患者60例,ASA Ⅰ～Ⅱ级.随机均分为3组,每组20例.3组开始均采用靶控输注丙泊酚(血浆浓度2 ～4 mg·L-1)诱导和维持麻醉,静注0.6 mg·kg-1罗库溴铵气管插管.采用TOF-Watch SX肌松监测仪行拇指内收肌肌松监测,待T1恢复5％开始输注罗库溴铵,调节输注速率始终维持T1值8％ ～ 10％,稳定5 min时为初始状态.随即七氟烷(S)组和地氟烷(D)组停止输注丙泊酚,分别吸入七氟烷和地氟烷并使呼气末浓度稳定于1.3 MAC,对照(P)组继续输注丙泊酚.记录3组随后罗库溴铵输注速率,停肌松药后T1恢复至25％所需时间,T1从25％恢复至75％所需时间(恢复指数)及TOFr(T4/T1)恢复至90％所需时间.结果 3组患者罗库溴铵初始状态输注速率相似,D组和S组输注速率随吸入时间延长而逐渐下降(P＜0.05),而P组则未见明显改变;D组和S组初始状态后各时点罗库溴铵输注速率均显著低于P组(P＜0.05);D组初始状态后50 min内各时点罗库溴铵输注速率均低于S组(P＜0.05),而50 ～70 min间差异则无统计学意义.与P组比较,D组和S组患者停药后T1恢复至25％时间、T125％恢复至75％时间和TOFr恢复至90％时间均显著缩短(P＜0.05);与S组比较,D组上述肌松恢复时间更短(P＜0.05).结论 吸入1.3MAC七氟烷和地氟烷均能显著降低老年患者罗库溴铵持续输注速率,一定时间内地氟烷的该作用强于七氟烷,且肌松恢复更迅速.

Objective: To observe the intraoperative influences on pharmacodynamics of rocuronium in children inhaling sevoflurane and desflurane for 40 min balance. Methods: Ninety children (ASAⅠ-Ⅱ) undergoing elective surgery with general anesthesia in Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University from July 2015 to May 2016 were randomly assigned into six groups (n=15): Sevoflurane group (group S1 and S2), Desflurane group (group D1 and D2) and Propofol group (group P1 and P2). Children in group D1, S1 and P1 were allocated to research the dose-effect relationship of rocuronium, children in group D2, S2 and P2 were allocated to research the time-effect relationship of rocuronium. TOF-Watch SX monitor was used to exert a train-of-four stimulation (TOF) at ulnar nerve in wrist, then the adductor pollicis muscle appeared muscle twitch 4 times in turn which was recorded T(1, )T(2, )T(3) and T(4) respectively. After the success of the muscle relaxant calibration, 1.3 MAC sevoflurane and desflurane were inhaled and maintained for 40 min respectively in children in Sevoflurane group (group S1 and S2) and Desflurane group (group D1 and D2), Plasma target controlled infusion of 3.5-4.0 μg/ml propofol was always administered in Propofol group (group P1 and P2). 75 μg/kg rocuronium was injected each time in group S1, D1 and P1 respectively. Maximum inhibited effect of T(1) was recorded after every injection until inhibition of T(1) more than 95% eventually. The method of cumulative dose four times was used to calculate the efficiency curve of rocuronium[median effective dose (ED(50)), 90% effective dose (ED(90)) and 95% effective dose (ED(95))]. 0.6 mg/kg rocuronium was injected respectively through vein in group S2, D2 and P2. The recovery times of muscle relaxant were recorded which including time of T(1) disappeared (onset time), T(1) from 0% to 5% (peak effect time), T(1) from 0% to 25% (clinical effect time), T(1) from 25% to 75% (recovery index), T(1) from 0% to 70% (internal effect time), T(4)/T(1) (TOFr) from 0% to 70% and 90%. Results: ED(50, )ED(90) and ED(95) in group D1 were 128.73, 212.45 and 245.78 μg/kg respectively. ED(50, )ED(90) and ED(95) in group S1 were 132.46, 218.94 and 252.30 μg/kg respectively. ED(50, )ED(90) and ED(95) in group P1 were 230.56, 381.02 and 439.55 μg/kg respectively. ED(50, )ED(90) and ED(95) in group D1 and S1 were significantly lower than those in group P1 (all P<0.05), but there was no significant difference between D1 and S1 group (P>0.05). Compared with group P2, the shorter onset time, the longer peak effect time and clinical effect time was observed in group D2 and S2, the longer recovery index, internal effect time and TOFr from 0% to 70% and 90% was observed in group S2 (all P<0.01). Conclusions: 1.3 MAC sevoflurane and desflurane inhaling for 40 min significantly reduces ED(50) and ED(95) of rocuronium, prolongs the onset time and action time of rocuronium in children. Sevoflurane can significantly prolong the recovery characteristics of rocuronium.

目的:观察吸入1.3 MAC七氟烷和地氟烷40 min麻醉下对老年患者术中罗库溴铵药效动力学的影响.方法:全麻下行择期手术的老年患者90例,ASA Ⅰ～Ⅱ级.随机均分为6组,每组15例.七氟烷组(S1组和S2组)和地氟烷组(D1组和D2组)分别吸入1.3MAC七氟烷和地氟烷并维持40 min,对照组(P1组和P2组)血浆靶控输注丙泊酚3.5～4μg/mL维持同样时间.采用TOF-Watch SX肌松监测仪行拇内收肌肌松监测.S1组、D1组和P1组中心静注罗库溴铵75 μg·kg-1·次-1,总量0.3 mg/kg,并记录每次用药后T1的最大阻滞效应,最终使T1抑制超过95％.采用四次累积剂量的方法计算量效关系曲线和ED50 、ED90、ED95.S2组、D2组和P2组患者则分别中心静脉注射罗库溴铵0.6 mg/kg,记录罗库溴铵给药完毕至T1消失时间(起效时间),T1从0％恢复至5％所需时间(高峰时间)、T1恢复至25％所需时间(临床肌松时间)、T1从25％恢复至75％所需时间(恢复指数)、T1恢复至70％所需时间(体内作用时间)以及TOFr恢复至70％和90％的时间.结果:D1组ED50 、EDg0和ED95分别为74.23 μg/kg、114.58 μg/kg和130.12 μg/kg,S1组ED50、ED90和ED95分别为80.57 μg/kg、125.04 μg/kg和141.89 μg/kg,P1组ED50、ED90和ED95分别为110.61 μg/kg、170.83 μg/kg和194.16 μg/kg.D1组和S1组的ED50、ED90和ED95均显著低于P1组(P＜0.05),而D1组和S1组之间则差异无显著性.D2组和S2组各作用时效指标均显著长于P2组(P＜0.05);而D2组和S2组间比较,除D2组的高峰时间明显增加外,其他作用时效指标均无统计学差异.结论:1.3MAC地氟烷和七氟烷40 min麻醉下老年患者罗库溴铵的ED50、ED95显著降低,作用时间则明显延长,而对此改变,两种吸入麻醉药之间则无统计学差异.

??小儿全麻恢复期间出现躁动是一种较为常见的临床现象，最近的研究显示高达30%的患儿会出现苏醒期躁动，其中绝大多数是发生在复苏室（PACU）［1］。术后躁动会伤害患儿并导致其PACU滞留时间延长，因此对入院、手术、出院均在当天完成的日间手术［2］，更须预防术后躁动的发生，保证当天患儿顺利出院。由于小儿沟通交流困难，对其术后躁动的良好护理有赖于护理人员的严谨细心观察和准确的护理干预，并结合镇静和镇痛干预，缓解患儿躁动的发生。本文旨在对小儿日间手术术后躁动的原因进行观察并实施相应的护理和药物干预。

OBJECTIVE To investigate the toxic effects and mechanisms of acute exposure to inhaled anesthetics of sevoflurane and isoflurane on hippocampus in neonatal SD rats.METHODS SD male rats of 7-day-old were exposed to 3.6 % sevoflurane and 2.3% isoflurane respectively for 6 h.TUNEL and activated caspase 3 immunohistochemical staining were used to detect neuron apoptosis.Transmission electron microscope was use for morphological observation of hippocampus neurons.Western blotting was applied to check the expression of activated caspase 3.RESULTSCompared with normal control group 2±2,neuron apoptosis was more remarkable in sevoflurane and isoflurane groups;the ammount of neuron apoptosis increased significantly to 13±2 and 22±5,respectively.There was statistical significance in neuron apoptosis number between sevoflurane and isoflurane groups.Misshapen nuclei,swelling mitochondria and endoplasmic reticula in sevoflurane and isoflurane groups were observed under an electron microscope.Western blotting showed that expression of activated cleaved caspase 3 increased significantly(P0.05)and isoflurane was inclined to cause more severe apoptosis neurodegeneration than sevoflurane(P 0.05).CONCLUSIONAcute exposure to sevoflurane and isoflurane could induce apoptosis neurodegeneration.Isoflurane could cause more insults to brain of rats than sevoflurane at an equivalent concentration.

目的 探讨短时间吸入NO对心肌缺血/再灌注损伤的保护机制.方法 60只雄性wistar大鼠随机分为三组(Ⅰ、Ⅱ、Ⅲ组),每组20只,通过腹腔注射氯胺酮(120mg/kg)和咪达唑仑(10mg/kg)施行麻醉,同时给予人工通气.结扎左冠状动脉导致心肌缺血10min后开放,再灌注24h.Ⅰ组为对照组,Ⅱ、Ⅲ组分别在再灌注前5min、60min吸入10%的NO,再灌注24h后结扎左冠状动脉,注入荧光剂,心脏离体冰冻切片,HE染色,测量心肌梗死范围,取大鼠血液和组织中的NO代谢产物定量检测.结果 大鼠吸收NO的速度(6.35±0.24)min内基本成线性分布,后趋于稳定.吸入NO后红细胞中的S-亚硝基硫醇、N-亚硝胺和亚硝酰基亚铁血红素水平均明显增加.再灌注前的5min、60min吸入NO的心肌梗死范围较未吸入NO分别减少28%、31%.结论 短时间吸入NO能够明显减少心肌再灌注损伤的范围,提示短时间吸入NO对心肌缺血/再灌注也同样有很好的保护作用.其机制可能是迅速通过血液从肺到心脏的NO代谢产物以生物活性形式发挥作用.

Aim To investigate the roles of different muscarinic receptors (M 4, M 5) subtype on rewarding effects induced by morphine and the changes of neuronal nitric oxide synthase(nNOS)expression in ventral tegmental area (VTA) of rats. Methods Antisense oligonucleotides (AS-ONs) technique, lateral ventricle injection, and nNOS immunohistochemistry were employed in the present study, conditioned place preference (CPP) model was used for evaluating the rewarding effects of morphine in rats.Results After rats were injected morphine (5 mg·kg -1, sc), the time that rats stayed in paired-morphine boxes was significantly lengthened, and the amount that nNOS positive neurons expressed in VTA obviously increased. 24 h before injection of morphine, pretreatment with M 5-antisense oligodeoxynucleotides (M 5-AS) (2 nmol, icv) significantly inhibited formation of CPP and activation of nNOS expression in VTA. After the morphine-induced CPP had been established, injection of M 5-AS (2 nmol, icv) reduced the time that rats stayed in paired-morphine boxes, and in VTA the amount of nNOS positive neurons also reduced. In contrast with M 5-AS, M 4-antisense oligodeoxynucleotides (M 4-AS) had no great effects on the morphine-induce CPP and the expression of nNOS positive neurons in VTA. In addition, locomotor activity in all rats had no obvious changes in study.Conclusions M 5 muscarinic receptor play an important role in the conditioned place preference induced by morphine; M 5 muscarinic receptor activate expression of nNOS positive neurons in VTA, which maybe involved in morphine reward.

吸入性肺炎(aspiration pneumonitis,AP)是一个古老而又有新进展的课题,这里所讨论的AP是指胃酸吸入性肺炎,又称Mendelson综合征.反流性胃内容物(主要是无菌性胃酸)吸入肺内,引起的急性化学性肺损伤,常发生在禁食后全麻且意识不清时,或意识障碍患者.

在五种毒蕈碱受体亚型中,M5毒蕈碱受体是最后被发现的,M5受体在大脑和内脏组织中含量最少[1].