丙泊酚联合咪达唑仑用于长时间显微外科手术患者的镇静
摘要
目的
手足显微外科手术通常在神经阻滞麻醉下完成,但在手指再造、甲瓣移植、关节移植等时间长而复杂的手术中,患者因长时间制动,止血带反应烦躁,或因经历多次手术产生焦虑恐惧,既影响了患者的身心,又使手术难以顺利进行,甚至影响术后恢复,对这样的手术患者实施适当的镇静是一个重要的临床课题。本研究旨在以听觉诱发电位指数(AAI)为监测指标,观察丙泊酚联合不同剂量咪达唑仑用于长时间显微外科手术患者的镇静效果,为此类手术患者镇静提供临床依据。
方法
选择40例美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,在臂丛神经阻滞麻醉和腰硬联合麻醉下行显微外科手术患者,预计手术时间＞6h。有以下情况者除外:听力障碍,精神或神经病史;对苯二氮卓类药物过敏;已知或疑有阿片药物依赖(含乙醇);重症肌无力。随机分成四组,每组10例。入室后,常规监测心电图(Electrocardiogram,ECG),无创平均动脉压(Mean Arterial Pressure,MAP),心率(HR),脉搏血氧饱和度(S_pO_2),丹麦Danmeter公司A-line监测仪监测AAI(Auditory Evoked Potential Index)。常规L_(2～3)腰硬联合麻醉,蛛网膜下腔注入0.5%布比卡因15mg,硬膜外向头端置管3cm。术中通过硬膜外追加0.75%布比卡因来维持麻醉。于前中斜角肌间沟行臂丛神经阻滞,给予0.894%甲磺酸罗哌卡因20ml,待麻醉效果确切完善,患者生命体征稳定,开始手术后,实施镇静。Ⅰ组给予生理盐水2ml,Ⅱ、Ⅲ、Ⅳ组分别给予咪达唑仑0.01mg/kg,0.02mg/kg和0.04mg/kg,1min后用微量泵持续静注丙泊酚5～10mg/kg·h。同时Ⅱ、Ⅲ、Ⅳ组分别按照0.01mg/kg·h,0.02mg/kg·h和0.04mg/kg·h的速率泵入咪达唑仑。待AAI降到40,调整丙泊酚用量使AAI维持在30～45,维持这种镇静状态5h。
观察指标:记录镇静诱导时间,丙泊酚用量,计算每公斤体重用药;记录镇静维持5h丙泊酚用量,计算每小时每公斤体重用药量;从停止给药到患者睁眼苏醒时间,术中知晓情况。记录给药1min后,AAI降至40,及以后第1、3、5h的AAI、MAP、HR和S_pO_2。
结果
1.一般材料:
四组患者在年龄,体重,手术时间无统计学差异(P＞0.05)。
2.AAI与警觉/镇静评分(OAA/S)评分之间关系
四组患者AAI值30～45时,OAA/S评分为0～1分。
3.MAP、HR及S_pO_2比较:
3.1四组患者MAP比较:
组内比较:四组患者MAP达到镇静状态较给药1min后下降,有统计学差异(P＜0.05)。达到镇静状态,1、3、5h末各组MAP无统计学差异(P＞0.05)。
组间比较:同时间点MAP比较,差异无统计学意义(P＞0.05)。
3.2.四组患者HR比较:
组内比较:四组患者HR达到镇静状态较给药1min后下降,但达到镇静状态后无差别。
组间比较:同时间点HR比较,差异无统计学意义(P＞0.05)
3.3.四组患者S_pO_2比较:各组患者S_pO_2均在99%以上,各组各时间点没有统计学差异。
4.丙泊酚用量、镇静诱导时间,苏醒时间。
4.1镇静诱导
镇静诱导时间t_1Ⅱ～Ⅳ组比Ⅰ组缩短(P＜0.01),Ⅲ～Ⅳ组无明显差别(P＞0.05)。丙泊酚用量V_1Ⅱ～Ⅳ组比Ⅰ组少(P＜0.01),Ⅱ组与Ⅲ组无明显差别,少于Ⅳ组(P＜0.05)。Ⅲ、Ⅳ组无显著性差异。
4.2镇静维持
镇静维持时丙泊酚用量V_2Ⅰ、Ⅱ组都高于Ⅲ、Ⅳ组(P＜0.05)。Ⅲ、Ⅳ组无显著性差异(P＞0.05)。
4.3苏醒时间
苏醒时间t_2Ⅳ组明显长于其它三组(P＜0.01)。Ⅱ、Ⅲ组无显著性差异(P＞0.05)。
5.术中知晓情况
Ⅰ组患者有两例能回忆手术中部分事件,其余患者对手术没有记忆。
结论
1.丙泊酚单用或者联合咪达唑仑,都能使四组患者达到满意的镇静状态。
2.丙泊酚联合咪达唑仑泵入能缩短镇静诱导时间。镇静诱导镇静维持,丙泊酚用量减少,但二者不呈剂量依赖性。
3.以AAI30～45为镇静目标,镇静诱导时丙泊酚联合咪达唑仑0.02mg/kg,镇静维持时丙泊酚联合咪唑安定0.02 mg/kg·h,能有效的避免术中知晓,苏醒时间不至延长,较好满足长时间手足显微外科手术镇静需求。
Objective:extremity microsurgeries were usually operated under nerve blocking anesthesia,howerer patients could felt dysphoric and afeard due to long-time caging,reaction to tourniquet,or the experences of multiple operations during the long-time subtile and complicated operation for example finger reconstruction,toenail flap transplanting,articulus transplanting and so on.Not only the patients were hured physically and mentally,but also the operations can't be proceeded swimmingly,even the postoperative recoveries were effected.So it's an important clinical topic to perform sedation for these patients.
The purpose of this study is to investigate the sedative effect of propofol combined with different doses of midazolam in patients undergoing long-time microsurgery,taking auditory evoked potential index(AAI)as a parameter,and to provide clinical bases of sedation for patients undergoing these operations.
Methods:Forty(American Society of Anesthesiologists)ASAⅠ～Ⅱpatients undergoing microsurgeries with brachial plexus block and combined spinal epidural anesthesia(CSEA)were randomly divided into 4 groups.The process of the operations were anticipated beyond 6 h.These should be excluded:hearing disturbance,history of mental disease and nervous disease,being hyperergic to benzodiazepine(BZ),drug addiction to opioid(including alcohol),myasthenia gravis. MAP(Mean Arterial Pressure),ECG(Electrocardiogram)、SpO_2(Pulse Oxygen Saturation)were continuously monitored during anesthesia.AAI(Auditory Evoked Potential Index)were monitored by A-line monitor made by Co.Danmeter in denmark.The CSEA were enforced on L_(2～3),0.5%bupivacaine 15 mg was infused into SAS(subarachnoid space).Epidural catheter was inserted by 3cm in cavitas epiduralis. The anaesthesia was maintained by adding 0.75%bupivacaine in cavitas epiduralis. The brachial plexus block was enforced in the intergroove between anterior and medial scalenus muscle by 0.894%ropivacaine 20ml.The operation started when the anaesthetic effect was certain and consummate,and the patients' vital sign were stable. Then the sedation program were executed.Normal saline(NS)2ml for groupⅠ, midazolam 0.01mg/kg,0.02mg/kg,0.04mg/kg for GroupⅡ,Ⅲ,Ⅳrespectively.1 min after given NS or midazolam,propofol was infused at a rate of 5～10mg/kg·h combined with midazolam at a rate of 0.01mg/kg·h,0.02mg/kg·h,0.04mg/kg·h for GroupⅡ,Ⅲ,Ⅳrespectively.After the AAI decreased to 40,the infusion rate of propofol was adjusted to keep AAI at the level of 30～45,and maintained the level by infusing propofol and midazolam for 5 h.
The dosages of propofol required for induction and maintenance was recorded. The emergence time and whether patients had awareness during the operation were recorded after the infusion stopped.The AAI、MAP、HR and S_pO_2 were recorded when 1 min after sedation administration,AAI decreasing to 40,the end of the 1st、3rd、5th hour after AAI decreasing to 40.
Results:
1.Demographic profile
The patients of the four groups were comparable in age,weight,time of operation,there were no differences among them.(P＞0.05).
2.The correlation between AAI and Observer's Assessment of alertness/sedation (OAA/S)
The OAA/S score was 0～1,when AAI was 30～45.
3.MAP、HR and S_pO_2
3.1 Change on MAP
Within the groups,MAP decreased after sedation,compared with 1min after administration(P＜0.05).There were no significant differerces at the end of the 1st、 3rd、5th hour after AAI decreasing to 40(P＞0.05).
There were no significant differences among the four groups at the corresponding points(P＞0.05).
3.2 Change on HR
Within the groups,HR was significantly slower after sedation,compared with 1 min after adminstration(P＜0.05).There were no significant differerces at the end of the 1st、3rd、5th hour after AAI decreasing to 40(P＞0.05).There were no significant differences among the four groups at the corresponding points(P＞0.05).
3.3 Change on S_pO_2
The S_pO_2 of all the patients were over 99%,and there were no significant differences among the four groups at the corresponding points(P＞0.05).
4.Dosage of Propofol,Induction time,Emergence time
4.1 sedation induction
Induction time t_1 was obviously shortened in GroupⅡ～Ⅳcompared with GroupⅠ(P＜0.01).There were no significant differences amongⅢ～Ⅳ(P＞0.05). Dosage of Propofol was reduced in GroupⅡ～Ⅳcompared with GroupⅠ(P＜0.01). There was no significant differences between groupⅡandⅢ,and between groupⅢandⅣ.
4.2 sedative maintenance
The dosage of Propofol in both GroupⅠandⅡwere larger than that in GroupⅢandⅣ(P＜0.05).There were no significant differerces between groupⅢandⅣ(P＞0.05).
4.3 Emergence time
The emergence time in GroupⅣwas dramatically longer than the other groups(P＜0.01).There were no significant differerces between groupⅡandⅢ(P＞0.05)
5.awareness during the operation
2 patients in groupⅠcould recall a fraction of event during the operation,and the other patients had no remembrance of the operation.
Conclusion:
1.All the patients could reached a satisfactory sedation by propofol alone or combined with midazolam during long-time microsurgeries.
2.The sedation induction period was shortened by combined with midazolam. The dosage of propofol reduced in the period of sedation induction and sedative maintenance.However there were no dependence of dosage between propofol and midazolam.
3.At the target sedative level of AAI30～45,the optimal dosage of midazloam for induction of sedation was 0.02mg/kg,and for maintenance of sedation was 0.02 mg/kg·h while combined with Propofol continuous infusion.That could avoid the remembrance during the operation,and the emergence time could not be prolonged.
手足显微外科手术通常在神经阻滞麻醉下完成,但在手指再造、甲瓣移植、关节移植等时间长而复杂的手术中,患者因长时间制动,止血带反应烦躁,或因经历多次手术产生焦虑恐惧,既影响了患者的身心,又使手术难以顺利进行,甚至影响术后恢复,对这样的手术患者实施适当的镇静是一个重要的临床课题。本研究旨在以听觉诱发电位指数(AAI)为监测指标,观察丙泊酚联合不同剂量咪达唑仑用于长时间显微外科手术患者的镇静效果,为此类手术患者镇静提供临床依据。
方法
选择40例美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,在臂丛神经阻滞麻醉和腰硬联合麻醉下行显微外科手术患者,预计手术时间＞6h。有以下情况者除外:听力障碍,精神或神经病史;对苯二氮卓类药物过敏;已知或疑有阿片药物依赖(含乙醇);重症肌无力。随机分成四组,每组10例。入室后,常规监测心电图(Electrocardiogram,ECG),无创平均动脉压(Mean Arterial Pressure,MAP),心率(HR),脉搏血氧饱和度(S_pO_2),丹麦Danmeter公司A-line监测仪监测AAI(Auditory Evoked Potential Index)。常规L_(2～3)腰硬联合麻醉,蛛网膜下腔注入0.5%布比卡因15mg,硬膜外向头端置管3cm。术中通过硬膜外追加0.75%布比卡因来维持麻醉。于前中斜角肌间沟行臂丛神经阻滞,给予0.894%甲磺酸罗哌卡因20ml,待麻醉效果确切完善,患者生命体征稳定,开始手术后,实施镇静。Ⅰ组给予生理盐水2ml,Ⅱ、Ⅲ、Ⅳ组分别给予咪达唑仑0.01mg/kg,0.02mg/kg和0.04mg/kg,1min后用微量泵持续静注丙泊酚5～10mg/kg·h。同时Ⅱ、Ⅲ、Ⅳ组分别按照0.01mg/kg·h,0.02mg/kg·h和0.04mg/kg·h的速率泵入咪达唑仑。待AAI降到40,调整丙泊酚用量使AAI维持在30～45,维持这种镇静状态5h。
观察指标:记录镇静诱导时间,丙泊酚用量,计算每公斤体重用药;记录镇静维持5h丙泊酚用量,计算每小时每公斤体重用药量;从停止给药到患者睁眼苏醒时间,术中知晓情况。记录给药1min后,AAI降至40,及以后第1、3、5h的AAI、MAP、HR和S_pO_2。
结果
1.一般材料:
四组患者在年龄,体重,手术时间无统计学差异(P＞0.05)。
2.AAI与警觉/镇静评分(OAA/S)评分之间关系
四组患者AAI值30～45时,OAA/S评分为0～1分。
3.MAP、HR及S_pO_2比较:
3.1四组患者MAP比较:
组内比较:四组患者MAP达到镇静状态较给药1min后下降,有统计学差异(P＜0.05)。达到镇静状态,1、3、5h末各组MAP无统计学差异(P＞0.05)。
组间比较:同时间点MAP比较,差异无统计学意义(P＞0.05)。
3.2.四组患者HR比较:
组内比较:四组患者HR达到镇静状态较给药1min后下降,但达到镇静状态后无差别。
组间比较:同时间点HR比较,差异无统计学意义(P＞0.05)
3.3.四组患者S_pO_2比较:各组患者S_pO_2均在99%以上,各组各时间点没有统计学差异。
4.丙泊酚用量、镇静诱导时间,苏醒时间。
4.1镇静诱导
镇静诱导时间t_1Ⅱ～Ⅳ组比Ⅰ组缩短(P＜0.01),Ⅲ～Ⅳ组无明显差别(P＞0.05)。丙泊酚用量V_1Ⅱ～Ⅳ组比Ⅰ组少(P＜0.01),Ⅱ组与Ⅲ组无明显差别,少于Ⅳ组(P＜0.05)。Ⅲ、Ⅳ组无显著性差异。
4.2镇静维持
镇静维持时丙泊酚用量V_2Ⅰ、Ⅱ组都高于Ⅲ、Ⅳ组(P＜0.05)。Ⅲ、Ⅳ组无显著性差异(P＞0.05)。
4.3苏醒时间
苏醒时间t_2Ⅳ组明显长于其它三组(P＜0.01)。Ⅱ、Ⅲ组无显著性差异(P＞0.05)。
5.术中知晓情况
Ⅰ组患者有两例能回忆手术中部分事件,其余患者对手术没有记忆。
结论
1.丙泊酚单用或者联合咪达唑仑,都能使四组患者达到满意的镇静状态。
2.丙泊酚联合咪达唑仑泵入能缩短镇静诱导时间。镇静诱导镇静维持,丙泊酚用量减少,但二者不呈剂量依赖性。
3.以AAI30～45为镇静目标,镇静诱导时丙泊酚联合咪达唑仑0.02mg/kg,镇静维持时丙泊酚联合咪唑安定0.02 mg/kg·h,能有效的避免术中知晓,苏醒时间不至延长,较好满足长时间手足显微外科手术镇静需求。
Objective:extremity microsurgeries were usually operated under nerve blocking anesthesia,howerer patients could felt dysphoric and afeard due to long-time caging,reaction to tourniquet,or the experences of multiple operations during the long-time subtile and complicated operation for example finger reconstruction,toenail flap transplanting,articulus transplanting and so on.Not only the patients were hured physically and mentally,but also the operations can't be proceeded swimmingly,even the postoperative recoveries were effected.So it's an important clinical topic to perform sedation for these patients.
The purpose of this study is to investigate the sedative effect of propofol combined with different doses of midazolam in patients undergoing long-time microsurgery,taking auditory evoked potential index(AAI)as a parameter,and to provide clinical bases of sedation for patients undergoing these operations.
Methods:Forty(American Society of Anesthesiologists)ASAⅠ～Ⅱpatients undergoing microsurgeries with brachial plexus block and combined spinal epidural anesthesia(CSEA)were randomly divided into 4 groups.The process of the operations were anticipated beyond 6 h.These should be excluded:hearing disturbance,history of mental disease and nervous disease,being hyperergic to benzodiazepine(BZ),drug addiction to opioid(including alcohol),myasthenia gravis. MAP(Mean Arterial Pressure),ECG(Electrocardiogram)、SpO_2(Pulse Oxygen Saturation)were continuously monitored during anesthesia.AAI(Auditory Evoked Potential Index)were monitored by A-line monitor made by Co.Danmeter in denmark.The CSEA were enforced on L_(2～3),0.5%bupivacaine 15 mg was infused into SAS(subarachnoid space).Epidural catheter was inserted by 3cm in cavitas epiduralis. The anaesthesia was maintained by adding 0.75%bupivacaine in cavitas epiduralis. The brachial plexus block was enforced in the intergroove between anterior and medial scalenus muscle by 0.894%ropivacaine 20ml.The operation started when the anaesthetic effect was certain and consummate,and the patients' vital sign were stable. Then the sedation program were executed.Normal saline(NS)2ml for groupⅠ, midazolam 0.01mg/kg,0.02mg/kg,0.04mg/kg for GroupⅡ,Ⅲ,Ⅳrespectively.1 min after given NS or midazolam,propofol was infused at a rate of 5～10mg/kg·h combined with midazolam at a rate of 0.01mg/kg·h,0.02mg/kg·h,0.04mg/kg·h for GroupⅡ,Ⅲ,Ⅳrespectively.After the AAI decreased to 40,the infusion rate of propofol was adjusted to keep AAI at the level of 30～45,and maintained the level by infusing propofol and midazolam for 5 h.
The dosages of propofol required for induction and maintenance was recorded. The emergence time and whether patients had awareness during the operation were recorded after the infusion stopped.The AAI、MAP、HR and S_pO_2 were recorded when 1 min after sedation administration,AAI decreasing to 40,the end of the 1st、3rd、5th hour after AAI decreasing to 40.
Results:
1.Demographic profile
The patients of the four groups were comparable in age,weight,time of operation,there were no differences among them.(P＞0.05).
2.The correlation between AAI and Observer's Assessment of alertness/sedation (OAA/S)
The OAA/S score was 0～1,when AAI was 30～45.
3.MAP、HR and S_pO_2
3.1 Change on MAP
Within the groups,MAP decreased after sedation,compared with 1min after administration(P＜0.05).There were no significant differerces at the end of the 1st、 3rd、5th hour after AAI decreasing to 40(P＞0.05).
There were no significant differences among the four groups at the corresponding points(P＞0.05).
3.2 Change on HR
Within the groups,HR was significantly slower after sedation,compared with 1 min after adminstration(P＜0.05).There were no significant differerces at the end of the 1st、3rd、5th hour after AAI decreasing to 40(P＞0.05).There were no significant differences among the four groups at the corresponding points(P＞0.05).
3.3 Change on S_pO_2
The S_pO_2 of all the patients were over 99%,and there were no significant differences among the four groups at the corresponding points(P＞0.05).
4.Dosage of Propofol,Induction time,Emergence time
4.1 sedation induction
Induction time t_1 was obviously shortened in GroupⅡ～Ⅳcompared with GroupⅠ(P＜0.01).There were no significant differences amongⅢ～Ⅳ(P＞0.05). Dosage of Propofol was reduced in GroupⅡ～Ⅳcompared with GroupⅠ(P＜0.01). There was no significant differences between groupⅡandⅢ,and between groupⅢandⅣ.
4.2 sedative maintenance
The dosage of Propofol in both GroupⅠandⅡwere larger than that in GroupⅢandⅣ(P＜0.05).There were no significant differerces between groupⅢandⅣ(P＞0.05).
4.3 Emergence time
The emergence time in GroupⅣwas dramatically longer than the other groups(P＜0.01).There were no significant differerces between groupⅡandⅢ(P＞0.05)
5.awareness during the operation
2 patients in groupⅠcould recall a fraction of event during the operation,and the other patients had no remembrance of the operation.
Conclusion:
1.All the patients could reached a satisfactory sedation by propofol alone or combined with midazolam during long-time microsurgeries.
2.The sedation induction period was shortened by combined with midazolam. The dosage of propofol reduced in the period of sedation induction and sedative maintenance.However there were no dependence of dosage between propofol and midazolam.
3.At the target sedative level of AAI30～45,the optimal dosage of midazloam for induction of sedation was 0.02mg/kg,and for maintenance of sedation was 0.02 mg/kg·h while combined with Propofol continuous infusion.That could avoid the remembrance during the operation,and the emergence time could not be prolonged.
引文
[1]Fiehn A.montoring aeareness during cardiac surgery[J].Annals of Cardiac Anaesthesia,2002,5:149-155.
[2]Urhonen E,Jensen EW,hund J.Changes in rapidly extracted anditory evoked potentials during tracheal intubation[J].Acta Anaesthesiol Scand,2000,44:743-748.
[3]Litvan H,Jensen EW,Galan J,et al.Comparison of conventional averaged and rapid averaged,autoregressive-based extracted auditory evoked potentials for monitoring the hypnotic level during propofol induction[J].Anesthesiology,2002,97:351-358.
[4]林汉生,夏苏建。利用SPSS进行随机化实验设计分组[J]。中华卫生统计,2005,22(6):397-398。
[5]李康华,唐萍玉。急诊足趾移植治疗撕脱性拇指缺损[J]。中国现代医学杂志,2002,12(11):38-39。
[6]刘俊杰,赵俊,主编.现代麻醉学[M].第2版.北京:人民卫生出版社,1997:645-808.
[7]LEI HY,XU SY,ZHANG QG.Comparison of Combined spinalepiduralanesthesia and general anesthesia for department of gynaecology endoscopic surgery[J].China Journal of Endoscopy,2003,9(10):57-58.Chinese
[8]王华民,李志学,曲仁海.腰麻硬膜外复合麻醉法10年临床分析[J].中华麻醉学杂志,1999,19(10):624.
[9]李忠田,景勇,曲伸.腰麻后去枕平卧释疑[J].临床麻醉学杂志,2002,18(6):335.
[10]王德明,张元信,何旭等。不同联合组织方法用于拇指再造术的对比研究[J]。中国现代医学杂志,2005,15(6)868-872。
[11]王明山,罗爱伦.腰一硬联合麻醉的不良反应[J].国外医学麻醉学与复苏分册,2002,23(3):161-162.
[12]梁华,陶国才。气管插管导管套囊压力和持续时间对家兔气管黏膜的影 响[J]。中华麻醉学杂志,2005,25(12):934-935。
[13]周海,潘晓军,王建华,马亿选,郭成浩。吸入不同时间高浓度氧对大鼠肺的损伤作用[J]。中华麻醉学杂志,2005,26(5):473-475。
[14]袁莉,潘晓军,赵勇,于文刚,类维富,王世端。犬气管插管全麻下吸入不同浓度氧时自由基及肺超微结构的变化[J]。临床麻醉学杂志,2003,19(2):94-97。
[15]王琳,李冬梅,石荣光等。拇指再造病人心理干预的临床研究[J]。CHINESE NURSING RESEARCH,2007,21(3):594-596.
[16]房明月,刘兰风。第二足趾移植再造拇示指患者的心理护理及康复指导[J]。华北煤炭医学院学报,2001,3(3):358.
[17]朱盛修,主编。现代骨科手术学[M].北京:人民卫生出版社,1997,3-4。
[18]胥少汀,主编。骨科手术并发症预防与处理[M]。北京:人民军医出版社,2002:35-36。
[19]申屠敏姣。烦躁患者约束体验的研究[J]。护理与康复,2004,3(5):291-292。
[20]谢素美,聂玉兰。二次骨折病人围手术期的心理护理[J]。实用医学杂志,2007,23(18):2849。
[21]徐志沽,段丽萍,王琨,等.焦虑和抑郁与胃食管反流病症状发生的相关研究[J]。中华医学杂志,2005,85(45),3210-3215。
[22]王凌,罗和生,姜齐宏。精神心理因素在肠易激综合征发病中的作用及性别差异研究[J].胃肠病学和肝病学杂志,2005,14(6):603-604。
[23]曹泽毅,主编。中华妇产科学。北京:人民卫生出版社,1999,603。
[24]刘晓芳。断指再植术后发生血管危象的原因分析及处理对策[J]。中华显微外科杂志,2005(3),28,274-276。
[25]腾国栋,胡晓莺,袁光海,汤海萍。精神因素对拇手指再造术后的影响[J]。中华手外科杂志,2007,23(3):159-161。
[26]周曙。意识的实验研究和方向[J]。基础科学,1995,4:13-14。
[27]郭力平。内隐和外显记忆的遗忘特点[J]。心理学报,2002,34(1): 29-35。
[28]孟迎芳,郭春彦。从认知神经的角度看内隐记忆和外显记忆的分离[J]。心理科学进展,2006,14(6):822-828。
[29]庄心良,曾因明,陈伯銮主编。现代麻醉学[M],北京,人民卫生出版社,2003:500-502.
[30]Ludbrook Gh,Upton RN,Martinez GA.Prolonged dysequilibrium between blood and brain concentrations of propofol during infusions in sheep[J].Acta Anaesthesiol Scand,1999,43:206-211.
[31]盖成林,古妙宁,林春水等。异丙酚麻醉诱导期间动脉和颈内静脉球部血药浓度的变化[J]。中华麻醉学杂志,2002,22(4):197-199。
[32]古妙宁,盖成林,林春水等。恒速静脉输注异丙酚时脑摄取的研究[J]。中华麻醉学杂志,2001,21(3):133-135。
[33]Enlund M,Andersson J,Hartvig P,et al.Cerebralnormoxia in the rhesus monkey during isoflurane- or propofol-induced hypotension and hypocapnia,despite disparate blood-flow patterns:a positron emission tomography study[J],Acta Anaesthesiol Scand,1997,41:1002-1010.
[34]Fiset P,Paus T,Daloze T,et al.Brain mechanisms of propofolinduced loss of consciousness in humans:a positron emission tomographic study[J].The J Neurosci,1999,19(13):5506-5513.
[35]Bonhomme V,Fiset P,Meuret P,et al.Propofol anesthesia and cerebral blood flow changes elicited by vibrotactile stimulation:a positron emission tomography study[J].J Neurophysiol,2001,85:1299-1308.
[36]McKernan RM,Whiting PJ.Which 6ABA_A receptor subtypes really occur in the brain? Trends Neurosci,1996,19:139-143.
[37]Krasowski MD,Koltchine VV,Rick CE,et al.Propofol and other intravenous anesthetics have sites of action on the gamma-aminobutyric acid type A receptor distinct from that for isoflurane.Mol Pharmacol,1998,53:530-538.
[38]Alkire MT,Haler RJ.Correlating in vivo anaesthetic effects with ex vivo receptor density data supports a GABAergic mechanism of action for propofol, but not for isoflurane[J]. Br J Anaesthesia, 2001, 86(5): 618-626.
[39]Sean MO'S, Wang LC, Harrison NL. Propofol increases agonist efficacy at the GABA_A receptor. Brain Research, 2000, 852:344-348.
[40]Matthew DK, Andrew J, Pamela F, et al. General anesthetic potencies of a series of propofol analogs correlate with potency for potentiation of γ-aminobutyric acid (GABA) current at the GABA_A receptor but not with lipid solubility. J Pharmacol exp ther, 2001, 297:338-351.
[41]Sheng M. Glutamate receptors put in their place. Nature, 1997, 386:221-223.
[42]Buggy DJ, Nicol B, Rowbotham DJ, et al. Effects of intravenous anesthetic agents on glutamate release: a role for GABAa receptor mediated inhibition. Anesthesiology, 2000, 92:1067-1073.
[43]Liachenko S, Tang P, Somogyi GT, et al. Comparison of anaesthetic and non-anaesthetic effects on depolarization-evoked glutamate and GABA release from mouse cerebrocortical slices. Br J Pharmacol, 1998, 123:1274-1280.
[44]Vinik HR, Kissin I. Midazolam for co-induction of thiopental anesthesia in patients[J].Anesthesiology, 1990, 73:A1216.
[45]Ghoneim MM, Robert I, Block, et al.The interactions of midazolam and flumazenil on human memory and cognition[J]. Anesthesiology, 2001,79:1183-1192.
[46]Roode A, Joop MA, Gerven V. A compoarision of the effect of propofol and midazolam on menory during two levels of sedation by using target-controlled infusion [J]. Aneath Analg, 2000:91:1056-1061.
[47]Hamaoka N, Oda Y, Hase I, Mieutani K, et al. Propofol decreases the clearance of midazolam by inhibiting CYP3A4:an in vivo and in vitro study.[J] Clin Pharmacol Ther 1999,66:110-117.
[48]戚志超,高嵩荣,卢振和。硬膜外麻醉下异丙酚联合咪达唑仑镇静对内隐记忆的影响[J]。中华麻醉学杂志,2004,24(3):172-175.
[49]刘志群,戚志超,邹伟伟。全凭静脉麻醉中丙泊酚联合咪达唑仑对内隐记忆的影响[J]。华中医学杂志,2006,30(2):91-94.
[50]孙红斌,张国峰,袁训芝,岳云。咪唑安定与异丙酚联合诱导时其剂量依赖性的临床观察[J]。天津医科大学学报,2003,9(2):264-266.
[51]Win NN,Fukayama H,Kohase H,et al.The different effects of intravenous propofol and midazolam sedation on hemodynamic and heart rate variability[J].Anesthesia And Analgesia,2005,101(1):97-102.
[52]王祥瑞,杭燕南,孙大金等.丙泊酚的剂量与镇静和呼吸抑制作用之间的关系[J].中华麻醉学杂志,1997,17:590-592.
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[2]Urhonen E,Jensen EW,hund J.Changes in rapidly extracted anditory evoked potentials during tracheal intubation[J].Acta Anaesthesiol Scand,2000,44:743-748.
[3]Litvan H,Jensen EW,Galan J,et al.Comparison of conventional averaged and rapid averaged,autoregressive-based extracted auditory evoked potentials for monitoring the hypnotic level during propofol induction[J].Anesthesiology,2002,97:351-358.
[4]林汉生,夏苏建。利用SPSS进行随机化实验设计分组[J]。中华卫生统计,2005,22(6):397-398。
[5]李康华,唐萍玉。急诊足趾移植治疗撕脱性拇指缺损[J]。中国现代医学杂志,2002,12(11):38-39。
[6]刘俊杰,赵俊,主编.现代麻醉学[M].第2版.北京:人民卫生出版社,1997:645-808.
[7]LEI HY,XU SY,ZHANG QG.Comparison of Combined spinalepiduralanesthesia and general anesthesia for department of gynaecology endoscopic surgery[J].China Journal of Endoscopy,2003,9(10):57-58.Chinese
[8]王华民,李志学,曲仁海.腰麻硬膜外复合麻醉法10年临床分析[J].中华麻醉学杂志,1999,19(10):624.
[9]李忠田,景勇,曲伸.腰麻后去枕平卧释疑[J].临床麻醉学杂志,2002,18(6):335.
[10]王德明,张元信,何旭等。不同联合组织方法用于拇指再造术的对比研究[J]。中国现代医学杂志,2005,15(6)868-872。
[11]王明山,罗爱伦.腰一硬联合麻醉的不良反应[J].国外医学麻醉学与复苏分册,2002,23(3):161-162.
[12]梁华,陶国才。气管插管导管套囊压力和持续时间对家兔气管黏膜的影 响[J]。中华麻醉学杂志,2005,25(12):934-935。
[13]周海,潘晓军,王建华,马亿选,郭成浩。吸入不同时间高浓度氧对大鼠肺的损伤作用[J]。中华麻醉学杂志,2005,26(5):473-475。
[14]袁莉,潘晓军,赵勇,于文刚,类维富,王世端。犬气管插管全麻下吸入不同浓度氧时自由基及肺超微结构的变化[J]。临床麻醉学杂志,2003,19(2):94-97。
[15]王琳,李冬梅,石荣光等。拇指再造病人心理干预的临床研究[J]。CHINESE NURSING RESEARCH,2007,21(3):594-596.
[16]房明月,刘兰风。第二足趾移植再造拇示指患者的心理护理及康复指导[J]。华北煤炭医学院学报,2001,3(3):358.
[17]朱盛修,主编。现代骨科手术学[M].北京:人民卫生出版社,1997,3-4。
[18]胥少汀,主编。骨科手术并发症预防与处理[M]。北京:人民军医出版社,2002:35-36。
[19]申屠敏姣。烦躁患者约束体验的研究[J]。护理与康复,2004,3(5):291-292。
[20]谢素美,聂玉兰。二次骨折病人围手术期的心理护理[J]。实用医学杂志,2007,23(18):2849。
[21]徐志沽,段丽萍,王琨,等.焦虑和抑郁与胃食管反流病症状发生的相关研究[J]。中华医学杂志,2005,85(45),3210-3215。
[22]王凌,罗和生,姜齐宏。精神心理因素在肠易激综合征发病中的作用及性别差异研究[J].胃肠病学和肝病学杂志,2005,14(6):603-604。
[23]曹泽毅,主编。中华妇产科学。北京:人民卫生出版社,1999,603。
[24]刘晓芳。断指再植术后发生血管危象的原因分析及处理对策[J]。中华显微外科杂志,2005(3),28,274-276。
[25]腾国栋,胡晓莺,袁光海,汤海萍。精神因素对拇手指再造术后的影响[J]。中华手外科杂志,2007,23(3):159-161。
[26]周曙。意识的实验研究和方向[J]。基础科学,1995,4:13-14。
[27]郭力平。内隐和外显记忆的遗忘特点[J]。心理学报,2002,34(1): 29-35。
[28]孟迎芳,郭春彦。从认知神经的角度看内隐记忆和外显记忆的分离[J]。心理科学进展,2006,14(6):822-828。
[29]庄心良,曾因明,陈伯銮主编。现代麻醉学[M],北京,人民卫生出版社,2003:500-502.
[30]Ludbrook Gh,Upton RN,Martinez GA.Prolonged dysequilibrium between blood and brain concentrations of propofol during infusions in sheep[J].Acta Anaesthesiol Scand,1999,43:206-211.
[31]盖成林,古妙宁,林春水等。异丙酚麻醉诱导期间动脉和颈内静脉球部血药浓度的变化[J]。中华麻醉学杂志,2002,22(4):197-199。
[32]古妙宁,盖成林,林春水等。恒速静脉输注异丙酚时脑摄取的研究[J]。中华麻醉学杂志,2001,21(3):133-135。
[33]Enlund M,Andersson J,Hartvig P,et al.Cerebralnormoxia in the rhesus monkey during isoflurane- or propofol-induced hypotension and hypocapnia,despite disparate blood-flow patterns:a positron emission tomography study[J],Acta Anaesthesiol Scand,1997,41:1002-1010.
[34]Fiset P,Paus T,Daloze T,et al.Brain mechanisms of propofolinduced loss of consciousness in humans:a positron emission tomographic study[J].The J Neurosci,1999,19(13):5506-5513.
[35]Bonhomme V,Fiset P,Meuret P,et al.Propofol anesthesia and cerebral blood flow changes elicited by vibrotactile stimulation:a positron emission tomography study[J].J Neurophysiol,2001,85:1299-1308.
[36]McKernan RM,Whiting PJ.Which 6ABA_A receptor subtypes really occur in the brain? Trends Neurosci,1996,19:139-143.
[37]Krasowski MD,Koltchine VV,Rick CE,et al.Propofol and other intravenous anesthetics have sites of action on the gamma-aminobutyric acid type A receptor distinct from that for isoflurane.Mol Pharmacol,1998,53:530-538.
[38]Alkire MT,Haler RJ.Correlating in vivo anaesthetic effects with ex vivo receptor density data supports a GABAergic mechanism of action for propofol, but not for isoflurane[J]. Br J Anaesthesia, 2001, 86(5): 618-626.
[39]Sean MO'S, Wang LC, Harrison NL. Propofol increases agonist efficacy at the GABA_A receptor. Brain Research, 2000, 852:344-348.
[40]Matthew DK, Andrew J, Pamela F, et al. General anesthetic potencies of a series of propofol analogs correlate with potency for potentiation of γ-aminobutyric acid (GABA) current at the GABA_A receptor but not with lipid solubility. J Pharmacol exp ther, 2001, 297:338-351.
[41]Sheng M. Glutamate receptors put in their place. Nature, 1997, 386:221-223.
[42]Buggy DJ, Nicol B, Rowbotham DJ, et al. Effects of intravenous anesthetic agents on glutamate release: a role for GABAa receptor mediated inhibition. Anesthesiology, 2000, 92:1067-1073.
[43]Liachenko S, Tang P, Somogyi GT, et al. Comparison of anaesthetic and non-anaesthetic effects on depolarization-evoked glutamate and GABA release from mouse cerebrocortical slices. Br J Pharmacol, 1998, 123:1274-1280.
[44]Vinik HR, Kissin I. Midazolam for co-induction of thiopental anesthesia in patients[J].Anesthesiology, 1990, 73:A1216.
[45]Ghoneim MM, Robert I, Block, et al.The interactions of midazolam and flumazenil on human memory and cognition[J]. Anesthesiology, 2001,79:1183-1192.
[46]Roode A, Joop MA, Gerven V. A compoarision of the effect of propofol and midazolam on menory during two levels of sedation by using target-controlled infusion [J]. Aneath Analg, 2000:91:1056-1061.
[47]Hamaoka N, Oda Y, Hase I, Mieutani K, et al. Propofol decreases the clearance of midazolam by inhibiting CYP3A4:an in vivo and in vitro study.[J] Clin Pharmacol Ther 1999,66:110-117.
[48]戚志超,高嵩荣,卢振和。硬膜外麻醉下异丙酚联合咪达唑仑镇静对内隐记忆的影响[J]。中华麻醉学杂志,2004,24(3):172-175.
[49]刘志群,戚志超,邹伟伟。全凭静脉麻醉中丙泊酚联合咪达唑仑对内隐记忆的影响[J]。华中医学杂志,2006,30(2):91-94.
[50]孙红斌,张国峰,袁训芝,岳云。咪唑安定与异丙酚联合诱导时其剂量依赖性的临床观察[J]。天津医科大学学报,2003,9(2):264-266.
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