颈椎前路手术加速康复外科实施流程专家共识

加速康复外科(ERAS)理念作为现代医学进步的里程碑之一,可减少术后并发症,加速患者的术后康复进程,节约医疗资源。ERAS理念在脊柱外科领域的应用尚处于起步阶段。颈椎前路手术是脊柱外科最常用的手术方式之一。针对颈椎前路手术,目前尚无完整的ERAS体系指导医护团队促进患者术后快速康复。因此,遵循循证医学的原则,在《脊柱外科加速康复——围术期管理策略专家共识》的基础上,结合颈椎前路手术的特点,经过全国专家组反复讨论,达成颈椎前路手术ERAS实施流程专家共识,供脊柱外科医护人员在临床工作中参考应用。

Effect of Local Wound Infiltration with Ketamine versus Dexmedetomidine Added to Bupivacaine on Inflammatory Cytokines, a Randomized Clinical Trial

Background: Ketamine or dexmedetomidine as an adjuvant to bupivacaine in local wound infiltration attenuated postoperative stress response, especially with ketamine in patients undergoing total abdominal hysterectomy. Objectives: Compare effect of local wound infiltration with ketamine or dexmedetomidine added to bupivacaine to bupivacaine alone on inflammatory cytokine response after total abdominal hysterectomy. Methods: Sixty female patients with endometrial carcinoma underwent total abdominal hysterectomy and scheduled to receive local wound infiltration before wound closure either with one of three;40 ml of 0.25% bupivacaine alone (C Group) or with the addition of 2 mg/kg ketamine (K Group) or 2 μg/kg dexmedetomidine (D Group). After extubation, they were followed up for postoperative interleukin 6 (IL6), IL1β, IL10, and TNF-α levels were assessed at baseline, pre-infiltration, 6, and 24 h by blood samples obtained from each patient, hemodynamic variables, analgesic profile and side effects. Results: Inflammatory cytokines response was attenuated in K and D groups, evidenced by decreased mean pro-inflammatory cytokines IL6, TNF-α, and increased anti-inflammatory IL10 at 6 and 24 h postoperatively compared to pre-infiltration levels (p ≤ 0.01) with preservation of IL1β at its preoperative level (p > 0.05). Attenuation was more in K and D groups than in the C group and was highest in the K group with decreased 1st request, total morphine consumption without serious side effect. Conclusion: Local wound infiltration with ketamine or dexmedetomidine added to bupivacaine has a good postoperative analgesic profile and attenuated cytokines inflammatory response more than bupivacaine alone after total abdominal hysterectomy, with highest attenuation in ketamine group.

多巴胺能神经元参与全身麻醉苏醒的研究进展

背景脑内多巴胺神经递质在学习、记忆、觉醒、情感和运动功能中发挥着重要作用。目前研究发现多巴胺能（dopaminergic, DA）神经元也参与全身麻醉诱导与苏醒，但其机制有待阐明。目的探讨多巴胺系统参与全身麻醉苏醒相关机制。内容腹侧被盖区（ventral tegmental area, VTA）和黑质致密区（substantianigra pars compacta, SNc）是中脑DA神经元的主要分布区，同时也是中脑皮质和纹状体中多巴胺通路的起点。无论通过光遗传学还是药物遗传学的方法增强中枢神经系统内的DA投射，均可促进全身麻醉的觉醒。相反，通过敲除多巴胺受体基因或毁损VTA核团可以抑制多巴胺的促觉醒效应。VTA DA神经元的活性记录显示，当受试者处于清醒状态时神经元活动增加，处于睡眠状态时神经元活动则减少。研究发现全身麻醉过程与睡眠的脑电图存在一定的相似性，同样全身麻醉苏醒与自然睡眠觉醒也有着相似的脑电图特征。有光遗传学的研究表明，激活VTA中的DA神经元能加快全身麻醉的苏醒。类似的，电刺激VTA能加快全身麻醉的苏醒，而电刺激SNc则不能产生相同的效应。因此，VTA中DA神经元对全身麻醉的苏醒可能比SNc中DA神经元产生更大的影响。趋向多巴胺参与了全身麻醉的苏醒，刺激VTA的DA神经元可为加快全身麻醉苏醒提供一种新的方法。