2020年 · 第100卷第33期

Elderly patients have a higher risk of serious complications during the recovery period due to preoperative co-existing diseases and decline in their own organ function. The infusion rate of anesthetic, sedative and analgesic drugs should be gradually reduced 10 to 20 minutes before the end of the operation. During this process, appropriate analgesic drugs should be given to prevent explosive pain in order to prevent pain stress response caused by tracheal intubation and surgical trauma. Recommended opioids include fentanyl 1-2 μ g/kg, sufentanil 0.1-0.2 μ g/kg, or remifentanil 1-2 ng/ml; Tramadol 50 mg, or flurbiprofen axetil 50 mg, or parecoxib sodium 40 mg may be combined. Patients with fragile pulmonary function or advanced age (>75 years) should reduce opioid doses to avoid their inhibitory effects on respiration. In addition, local infiltration of 0.5% ~1.0% ropivacaine 10~20 ml in surgical wounds is also very effective in reducing pain during the recovery period of patients. Multimodal analgesia during the recovery period in elderly patients can help improve the success rate of extubation. Intraoperative continuous infusion of appropriate doses of dexmedetomidine helps to enhance tolerance to endotracheal intubation in elderly patients during the recovery period.

hypertensive intracerebral hemorrhage (HICH) is a disease caused by pathological changes in intracranial arterioles caused by long-term hypertension, and hyaline or fibrous degeneration of blood vessel walls, which weakens the elasticity of blood vessel walls and leads to blood vessel rupture and bleeding. When the patient is emotionally agitated, excessive mental or physical activity, and other factors cause a drastic increase in blood pressure, it can cause cerebral blood vessel rupture and bleeding. HICH is one of the serious complications of hypertension, and the incidence rate in European and American countries accounts for 9% to 28% of stroke^[1,2,3]The incidence rate of stroke in China accounts for 19% to 48%^[3,4]。 The common hemorrhage sites of HICH include basal ganglia, ventricles, thalamus, cerebellum, brainstem, lobes and subcortex, among which the lobes and subcortex are mostly microaneurysm rupture hemorrhage caused by vascular amyloidosis. Due to the extremely high mortality and disability rates of HICH, it has resulted in a heavy socio-economic burden^[1,2]。 In 2019, Lancet reported 25 types of diseases that caused deaths in the Chinese population between 1999 and 2017, with stroke leading the way with high mortality and disability rates^[3]。 Therefore, strengthening the primary and secondary prevention of HICH and improving the clinical treatment ability and level of HICH have become important tasks at present. At present, HICH has been included in the four categories of major chronic diseases focused on prevention and treatment in the Healthy China Action (2019-2030). With the development of imaging technology, CT scan has become an important auxiliary examination method in the diagnosis and treatment of cerebral hemorrhage. It is non-invasive, rapid and simple, and is helpful for the formulation of diagnosis and treatment plan, evaluation of treatment effect and prognosis.

Pain causes a series of discomfort reactions. During the development of neuropathic pain, a series of abnormal changes can occur in the neuroactivity of undefined zone (ZI) and posterior thalamic nucleus (Po), but the specific mechanism is still unknown. In particular, the exact cell type and molecular mechanism of the ZI-Po neural circuit for pain regulation are still unclear. The study found that parvalbumin (PV) -positive neurons of ventral ZI (ZIv) can project to Po (ZIv-Po), directly participating in and promoting pain behavior, while when the ZIv-Po circuit is selectively inhibited, the basal pain domain of mice increases. Furthermore, it was also found that the axonal ends of the ZIv-Po loop specifically express cannabinoid type 1 receptors (CB1Rs) and that cannabinoids alleviate pain responses through presynaptic inhibition. In further pathological pain models, selective inhibition of the ZIv-Po circuit or injection of cannabinoids in the Po can alleviate pain behavior. These results illustrate the key role of the ZIv-Po circuit in regulating pain behavior and the key mechanism by which endocannabinoids inhibit pain behavior by regulating the ZIv-Po circuit.

The incidence of complications of pancreatic surgery is still high, mainly caused by gastrointestinal complications (such as pancreatic fistula). Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are commonly used for pancreatic surgical analgesia. The study aimed to investigate whether patient-controlled intravenous analgesia reduces the incidence of gastrointestinal complications of pancreatic surgery. 371 patients undergoing elective pancreaticoduodenectomy between June 30, 2015 and October 1, 2017 at nine European pancreatic surgery centers were enrolled. Randomized to PCIA (n =185) and EDA (n=186), using the modified intention-to-treat analysis and completed treatment analysis of 248 patients (124 in each group) from 22 February to 25 April 2019.

Functional magnetic resonance imaging (MRI) and electrophysiological studies have shown that the formation of consciousness depends on large-scale thalamic-cortical and cortical-cortical interactions. However, it is unclear how neurons in different cortical layers and neural circuits function. The study simultaneously recorded the electrical activity of each layer of the centrolateral thalamus (CL) and frontoparietal cortex in rhesus monkeys in waking, sleeping, and anesthetic states, respectively, and found that neurons located in the thalamus and deep cortical layers were most sensitive to changes in the level of consciousness, whether in natural sleep or in unconscious states induced by different anesthetics. Deep cortical neuronal activity is maintained through interactions with the CL region. The level of consciousness also depends on the feedback provided by deep neurons to superficial (rather than deep) neurons, suggesting that remote feedback and intracortical column signaling are very important. To show the causal relationship, the researchers electrically stimulated the CL region of the macaques under anesthesia, which effectively aroused the macaques (or effectively caused the macaques to appear "awake"). The effects of this manipulation depend on the specific site of stimulation and the specific frequency. The study showed that specific layers of the thalamic cortex are associated with consciousness, and in this article, the researchers reported a method to reduce consciousness disorders through targeted deep brain stimulation.