不同麻醉方法用于剖宫产手术的利弊分析与临床抉择

本文系统详细的阐述了妊娠期间妇女主要的病理生理变化及其对麻醉的不良影响,指出了剖宫产手术时麻醉处理具有一定的特殊性,并且分析了不同的麻醉方法用于剖宫产手术时所具有的优缺点,最后作者对剖宫产手术时如何合理科学的选择麻醉方法进行了必要的临床思考。     

心血管手术麻醉中的辩证思维

马克思主义的辩证思维在临床实际工作中具有重要的意义.从心血管手术麻醉的特点出发,具体分析了在实施心血管手术麻醉中用到的几种思维方法,论述了这些方法在此种麻醉中运用的必要性及可行性.     

右美托咪定对鼻内镜手术患者血流动力学及苏醒期的影响

探讨鼻内镜手术时应用右美托咪定对其血流动力学及苏醒期的影响。选择100例行鼻内镜的择期手术患者,随机分为两组,右美托咪定组（D组）,持续泵入右美托咪定0.4μg·kg-1·h-1从麻醉诱导开始到拔管结束;对照组（C组）,持续泵入相同剂量的生理盐水。诱导药物均为依托咪酯0.3mg/kg,舒芬太尼0.4μg/kg,罗库溴铵0.6mg/kg,术中以丙泊酚6mg·kg-1·h-1、瑞芬太尼0.1μg·kg-1·min-1维持。观察并记录诱导前5min,手术开始后10min及30min,手术结束时,拔管时及拔管后2min的MAP及HR;记录术野质量和术中出血量、手术时间和拔管时间、拔管时躁动的发生率、呛咳评分、拔管后患者的Ramsay镇静评分。结果 D组在拔管时及拔管后2min血压和心率与C组相比降低（P〈0.05）;D组的术野质量优于C组（P〈0.05）,术中出血量D组少于C组（P〈0.05）;两组的手术时间和拔管时间差异无统计学意义;拔管时躁动的发生率及呛咳评分D组低于C组（P〈0.05）;D组拔管后患者的Ramsay镇静评分高于C组（P〈0.05）。术中应用右美托咪定,可使鼻内镜手术患者术中血流动力学更稳定,苏醒期更为平稳。     

Coping variables as predictors of perioperative emotional states and adjustment

Abstract

Surgery, regardless of its kind and severity, can be regarded as a major stress situation for any patient. High preoperative emotional arousal may negatively influence adaptation during surgery and, consequently, rate of postoperative recovery. In a series of previous studies, our research group analyzed the influence of dispositional and actual coping on subjective and objective stress indicators before, during, and after surgery. The present study investigates the influence of the dispositional coping variables vigilance and cognitive avoidance on actual surgery-related coping, state anxiety, and indicators of intra- and postoperative adjustment. The sample consisted of 42 male and 42 female patients undergoing elective maxillofacial surgery under general anaesthesia. Dispositional coping was measured on the dimensions vigilance and cognitive avoidance with the Mainz Coping Inventory. Actual surgery-related coping was assessed by means of a newly constructed inventory containing items to measure the four dimensions avoidance, vigilance, positive restructuring, and seeking social support.

Self-reported state anxiety was differentiated according to the cognitive, affective, and somatic components. The patients' adaptation was assessed by measuring doses of the narcotic agents used for induction of anaesthesia, the intraoperative status, and the amount of postoperative (analgesic and psychotropic) medication. Significant effects of coping mode, gender, and time of measurement were observed on the cognitive, affective and somatic component of state anxiety, the indicators of intraoperative adaptation and on postoperative medication. Also, patients' actual coping behavior could partly be predicted by dispositional coping. Results indicate that actual coping behavior and gender should be taken into account when trying to predict adaptation and developing psychological preparatory intervention programs.     

阿霉素对心肌影响的实验研究

阿霉素(adriamycin,ADM)临床上广泛用于多种恶性肿瘤的治疗,但ADM可致严重的心肌毒性。目前许多肿瘤疾病采取先化疗后麻醉、手术治疗方案,化疗药对心肌的损伤并没有引起临床医生的足够重视,尤其是麻醉科医生,我们应慎重考虑阿霉素等化疗药对心肌的影响,保障围手术期的安全。     

Acceptably aware during general anaesthesia: ‘Dysanaesthesia’ – The uncoupling of perception from sensory inputs

This review makes the case for ‘dysanaesthesia’, a term encompassing states of mind that can arise in the course of anaesthesia during surgery, characterised by an uncoupling of sensation and perceptual experience. This is reflected in a macroscopic, functional model of anaesthetically-relevant consciousness. Patients in this state can be aware of events but in a neutral way, not in pain, sometimes personally dissociated from the experiences. This makes events associated with surgery peripheral to their whole experience, such that recall is less likely and if it exists, makes any spontaneous report of awareness unlikely. This state of perception–sensation uncoupling is therefore broadly acceptable (a minimum requirement for acceptable anaesthesia) but since it is likely a dose-related phenomenon, may also represent a precursor for awareness with adverse recall. This hypothesis uniquely explains the often inconsistent responses seen during the experimental paradigm of the ‘isolated forearm technique’, wherein apparently anaesthetised patients exhibit a positive motor response to verbal command, but no spontaneous movement to surgery. The hypothesis can also explain the relatively high incidence of positive response to relatively direct questions for recall (e.g., using the Brice questionnaire; ∼1:500; the vast majority of these being neutral reports) versus the very low incidence of spontaneous reports of awareness (∼1:15,000; a higher proportion of these being adverse recollections). The hypothesis is consistent with relevant notions from philosophical discussions of consciousness, and neuroscientific evidence. Dysanaesthesia has important implications for research and also for the development of appropriate monitoring.     

孕妇非产科手术麻醉的评估和思考

临床上约有1%~2%的孕妇在孕期接受非产科手术麻醉;因孕期生理改变和手术麻醉对孕妇、胎儿的影响,加之妊娠合并心脏病、糖尿病等特殊病例以及现代腔镜手术、无痛人流特殊技术等复杂因素,为确保孕妇与胎儿安全,术前充分的评估、恰当的麻醉方法、药物选择与术中调控是我们必须重视与思考的课题。     

Keeping the patient asleep and alive: Towards a computational cognitive model of disturbance management in anaesthesia

We have analysed rich, dynamic data about the behaviour of anaesthetists during the management of a simulated critical incident in the operating theatre. We use a paper based analysis and a partial implementation to further the development of a computational cognitive model for disturbance management in anaesthesia. We suggest that our data analysis pattern may be used for the analysis of behavioural data describing cognitive and observable events in other complex dynamic domains.     

Evaluation of psychological stress before general anesthesia

Pre-operative fear is not only a psychologically stressing phenomenon for the patient, but also a considerable risk factor due to its somatical correlative. In a study, 150 patients who were to undergo planned surgery under general anaesthesia were questioned about their fears and worries concerning the anaesthetic. Self-rating scales and rating scales by doctors and a complaints analysis curve were used in addition to an interview system on illnesses and specific previous experiences. 54% of the patients were, according to specific criteria, assessed as being anxious or very anxious (for example diffused anxiety, premature weakening of the anaesthetic effect, worry about not waking up out of the anaesthetic). Several factors which could have an anxiety-lessening or increasing effect and which are of importance for the psychological preparation for an operation were deduced from the investigation.     

Infantile spasms: facial expression of affect before and after epilepsy surgery

This is a longitudinal study of facial expression of affect in 28 children with intractable infantile spasms who underwent epilepsy surgery. After a mean follow-up period of 1.8 years, there was a significant increase in positive affect, a significant decrease in neutral affect, and no change in negative affect during a nonverbal communication paradigm. These findings were unrelated to surgical (i. e., side of surgery, type of surgery) or seizure-related variables (i.e., seizure control, age at onset of illness, duration of illness, change in antiepileptic drugs). Comparison of affect in a subgroup of 16 patients with those of 32 normal subjects suggest a normal age-related increase in the use of positive affect. Both before and after surgery, the patients used the most positive affect while not communicating. They also used significantly more positive affect during while requesting objects or assistance rather than during social referencing. Intractable infantile spasms might be associated with reduction in the facial expression of positive affect and with impaired use during social communication.     

麻醉方式的临床决策

外科手术的进步离不开麻醉的配合,麻醉方式的抉择非常重要。如果麻醉达不到预期效果,不仅可以导致手术失败、也会给患者的身心带来伤害、甚至会由此引起医疗纠纷。科技进步、社会发展应运而生微创医学、医学人文学,这是社会的进步和必然趋势,也是麻醉方式选择的理论依据。     

Substitutes for leadership in anaesthesia teams and their impact on leadership effectiveness

In this study we aim to increase our understanding of leadership in anaesthesia teams by investigating the relationship between substitutes for leadership, leadership behaviour, and team performance in situations with varying levels of routine and standardization. The present study relied on video recordings of 12 anaesthesia teams in a simulated setting with the occurrence of a nonroutine event. Clinical team performance was measured by the speed of adequate team reaction to this event. The leadership behaviours observed were coded either as content oriented (e.g., information transmission) or structuring (e.g., assigning tasks). Results showed that leadership behaviour changed depending upon the level of routine of a situation, the degree of standardization, and, to some extent, on the experience of team members. Leadership tends to be positively related to team performance during nonroutine and low standardized situations but negatively related to team performance in routine and highly standardized situations. Furthermore, leadership is only slightly related to team member experience. This study improves our understanding of influences of substitutes for leadership on successful leadership behaviour in anaesthesia teams. The findings also lead to suggestions for both further research and the enhancement of team leadership in critical care.     

Delayed recovery of working memory following day‐case surgery

Post‐operative recovery of cognitive function is an important outcome measure following surgical anaesthesia. This study examined the influence of task complexity in 12 patients undergoing elective day‐case surgery using reaction time tasks that differed in their stimulus‐response mapping rules (compatible, incompatible, working memory). Tasks were administered at baseline, and at 1, 4 and 24 hours post‐surgery. Compared to a reference group of 18 non‐anaesthetised volunteers, the patient group showed considerable slowing one hour post‐operatively. This slowing remained at the time of discharge (4‐hours), was absent the next day, and did not vary as a function of task complexity. Only attentional lapses in the working memory task were sensitive to the recovery process and residual impairment remained the next day. The findings indicate that tasks requiring efficient access to working memory are impaired for longer than tasks simply requiring access to information passively retained in short‐term memory. Copyright © 2006 John Wiley & Sons, Ltd.     

麻醉告知与手术告知纠纷案问题探讨

麻醉告知和手术告知是两项独立的医疗活动,术后不良后果既可由手术引起,亦可由麻醉引起。术后不良后果发生原因的确定应作为医疗纠纷中责任划分的重要依据。案例表明,麻醉告知和手术告知在法律上没有单独存在的必要,依法完善手术风险的告知义务已成为医务工作者面临的新问题。     

Filling of the Circle of Willis in carotid angiography using halothane anesthesia

A comparative study of 150 carotid angiographies carried out under local anaesthesia and the same number under halothane anaesthesia did not show any great deviation from the well-known filling rates of the counter-lateral carotid region and the ipsilateral A. cerebri posterior nor any striking differences in the two methods of anaesthesia which could convince of a favourable influence of halothane on the demonstration of the vessels. The causative factors of the filling of adjacent vascularisation regions can certainly only be explained from the complex co-action of physiological and any external factors in cerebral angiography.     

Negative perfectionism increases the risk of fatigue following a period of stress

Abstract

There is a considerable amount of research concerning (he relationship between psychological variables and the postoperative outcome of surgery. However, little attention has been paid to the potential influence of psychological factors on infra-operative variables, most notably on anaesthetic requirement. The present study investigates the influence of surgery-related trail and slate anxiety as well as of dispositional and surgery-related actual coping on several indicators of intra- and postoperative adjustment. In addition, a possible mediating effect of stress-induced analgesia on the relationships between anxiety, coping, and intraoperative anaesthetic requirements was evaluated. Sixty-one patients undergoing elective lumbar iniclcotomy completed questionnaires regarding anxiety and coping variables one day before surgery. Intraoperative adjustment was assessed by measuring EEG-controlled anaesthetic requirements for induction and maintenance of anaesthesia, β-endorphin plasma concentration was collected preoperatively in the induction room. Postoperative outcome was assessed on the third day after surgery by questionnaires regarding pain experience, physical condition and emotional state. For preoperative anxiety as well as vigilant coping behaviour, there were opposite relationships with subjective measures of adjustment (e.g. self-reported postoperative pain experience), on the one side, and objective measures on the other (e.g., intraoperative anaesthetic requirement). Stress-induced analgesia was found for the subgroup of high-anxious patients. The results indicate that psychological programmes aimed at facilitating patients' perioperative adjustment should consider the different effects of anxiety and coping on subjective and objective measures.     

浅谈门诊手术中局部麻醉的彻底性

门诊手术没有麻醉师的介入,容易存在局部麻醉不彻底的情况。随着医学模式的转变,门诊手术中必须保证局部麻醉的彻底性。外科医师需要从人文关怀的角度出发,结合好几个具体环节,做到彻底的局部麻醉,才能赢得病人的终生信任。     

A Sequential Examination of Parent–Child Interactions at Anesthetic Induction

Parental presence is often employed to alleviate distress in children within the context of surgery under general anesthesia. The critical component of this intervention may not be the presence of the parent per se, but more importantly the behaviors in which the parent and child engage when the parent is present. The purpose of the current study was to examine the sequential and reciprocal relationships between parental behaviors and child distress during induction of general anesthesia. Participants were 32 children (3–6 years) receiving dental surgery as a day surgery procedure, and their parents. A modified Child Adult Medical Procedures Interaction Scale-Revised was used to code parent and child behaviors. Initial child distress led to increased parental provision of reassurance and decreased provision of physical comfort. Our findings may inform the development of preoperative preparation programs whereby parents can be appropriately educated about what behaviors will be helpful/unhelpful for their child during induction of general anesthesia.     

关于监测深低温停循环主动脉手术期间脊髓缺血性损伤的思考

脊髓缺血再灌注损伤（spinal cord ischemic reperfusion injury,SCIRI）是深低温停循环（deep hypothermic circulatoryarrest,DHCA）主动脉手术期间一种致命性的并发症,它对患者和其家属及医务人员带来严重的身心危害。在DHCA主动脉手术期间早期监测...     

七氟醚预处理对腹腔镜胃肠手术肝功能的影响

了解七氟醚预处理对腹腔镜胃肠手术术后肝功能变化的影响。选取80例择期行腹腔镜胃癌、结肠癌、直肠癌根治术者,随机分为2组。七氟醚组（S组）于麻醉诱导后CO2气腹建立前吸入0．8％～1．5％七氟醚30min ,对照组（C组）吸入氧气。检测2组患者术前,术后1d、2d、3d及7d肝功能（ALT、AST、TB、DB、TP、ALB）。结果七氟醚组术后1d、2d、3d的ALT及AST 水平低于对照组,且七氟醚组内气腹时间＞2．5h者术后1d、2d的 ALT 增长率（4％）低于≤2．5h者（10％）,术后2d、3d的ALT降低率,气腹时间＞2．5h者（25％）高于≤2．5h者（23％）。七氟醚预处理对腹腔镜胃肠手术术后肝功能有一定保护作用,且气腹时间越长,保护作用越明显。