[Summary] Postoperative cognitive dysfunction ( POCD) is a common central nervous system complication after anesthesia and surgery.The mechanisms of POCD are not clear yet.The article reviewed several potential mechanisms that have been reported. Further researches are needed to identify the pathophysiologic progress of POCD, which have great clinical and economic values.

Objective To investigate the value of employing pulse indicator continuous cardiac output (PiCCO) for cardiac function monitoring in patients with severe septic shock.Methods A prospective observation was conducted.Thirty-six septic shock patients in Department of Critical Care Medicine of Peking University Third Hospital admitted from August 2011 to December 2013 were enrolled.According to the degree of severity,the patients were divided into PiCCO monitor group and routine monitor group.The PiCCO monitor provided a continuous assessment of fluid resuscitation,vasopressors and inotropes infusion in the patients with severe septic shock.The following cardiac function parameters were assessed in severe septic shock patients on the 1st and 3rd day after intensive care unit (ICU)admission:cardiac index (CI),global ejection fraction (GEF),rate of left ventricular pressure increase (dp/dt max),echocardiography,and blood troponin T (TNT) and B-type natriuretic peptide (BNP).The central venous pressure (CVP),mean arterial pressure (MAP) and the time reaching their standard values,and the norepinephrine dosage and 3-day fluid balance in severe septic shock patients were compared between milrinone and non-milrinone usage groups.The severity degree and outcome were compared between PiCCO monitor group and routine monitor group.Results There were 15 patients in PiCCO monitor group and 21 in routine monitor group among 36 septic shock patients.① In 15 patients with PiCCO monitoring,the patients with decreased CI,GEF,and dp/dt max accounted for 40.0％,93.3％,and 33.3％ at 1 day after ICU admission,and accounted for 60.0％,93.3％,and 60.0％ at 3 days after ICU admission,and it showed that CI,GEF,and dp/dt max was not improved at 3 days after ICU admission.Echocardiography showed that 35.7％ patients had lower left ventricular ejection fraction (LVEF) at 1 day after ICU admission,71.4％ and 71.4％ of patients,respectively,had lower early diastolic mitral flow velocity/early diastolic myocardial velocity (E/Em) and early diastolic mitral flow velocity/end diastolic mitral flow velocity (E/A).Three days after ICU admission,80％ of patients with low LVEF value turned to normal,and diastolic dysfunction was ameliorated in 50％ patients.At 1 day after ICU admission,higher TNT was found in 92.9％ of patients,higher BNP in 100％ of patients,and 3 days after ICU admission,71.4％ and 78.6％ patients showed a decrease in TNT and BNP,respectively.② In PiCCO monitor group,there were no significant differences in initial CVP,MAP and their time reaching standard values,norepinephrine dosage between milrinone group (n =8) and non-milrinone group (n =7).However,3-day intake of liquid in milrinone group was significantly higher than that in non-milrinone group (mL:8 324±3 962 vs.4 372±2 081,t =-2.362,P =0.034).③ Compared with routine monitor group,there was a significant elevation in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,duration of mechanical ventilation,length of ICU stay and 28-day hospital mortality in PiCCO monitor group [APACHE Ⅱ score:20.67 ± 6.15 vs.14.71 ±4.67,t =-3.304,P =0.002; SOFA score:9.53±3.00 vs.7.52± 1.97,t =-2.433,P =0.020; duration of mechanical ventilation (hours):132 (54-310) vs.63 (14-284),Z =-2.295,P =0.022; length of ICU stay (days):7 (4-15) vs.5 (1-14),Z =-2.360,P =0.018; 28-day hospital mortality:26.7％ vs.0,P =0.023].Conclusion With the use of the PiCCO hemodynamic monitoring in patients with severe septic shock,more comprehensive values of blood volume,systemic vascular resistance and cardiac function can be obtained for guiding fluid resuscitation and selection of vasopressor and inotropic drugs.

Objective To evaluate the key points of anesthetic management for retroperitoneoscopic nephrectomy combined with inferior vena cava ( IVC ) tumor thrombectomy. Methods Perioperative clinical data of 3 patients undergoing retroperitoneoscopic nephrectomy combined with IVC tumor thrombectomy from December 2010 to June 2014 were retrospectively analyzed.There were 2 cases of level Ⅰthrombus and 1 case of level Ⅱthrombus.All the patients were given general anesthesia with intubation.Brief inferior vena cava occlusion was performed in the patient with level Ⅱ thrombus. Results The operation was completed smoothly in all the cases without conversions to open surgery. The operating time was 244, 333, and 289 min, respectively. The total IVC control time for level Ⅱ thrombus was 10 min.No intraoperative pulmonary embolism and other severe anesthetic complications occurred. One patient with level ⅠIVC thrombus was extubated and sent back to surgical ward after surgery, and the remaining 2 patients underwent intensive care monitoring overnight and were extubated and discharged to surgical ward on the next day. Conclusions Retroperitoneoscopic nephrectomy and IVC thrombectomy is a brand-new, difficult but feasible procedure. Anesthesiologist should have a full recognition of surgical procedures and make perfect anesthetic plan to ensure close collaboration. Furthermore, circulatory swing during IVC clamping and perioperative severe complications such as pulmonary embolization and massive hemorrhage cannot be neglected.

Objective To investigate the alleviative effects of lidocaine postconditioning on pulmonary injury following ischemia reperfusion. Methods Seventy-two adult SD rats were randomized to 4 groups; sham group, ischemia-reperfusion (I-R) group, ischemic postconditioning(IPC) group and lidocaine postconditioning group. The pulmonary ischemia-reperfusion model was established by occlusion of the left hilum of lung for 45 min and the reperfusion was taken by removing the clamp for 2 h. At the moment of reperfusion, lidocaine 4 mg/kg was injected as a priming dose following a continuous rate of 4 mg/(kg · h). PaO_2, TNF-α, W/D of left lung, the level of MDA of left lung tissue were measured. At the end of reperfusion left lung was removed for microscopy. Results After reperfusion PaO_2 of lidocaine group was much higher than that of I-R group (P<0.05). Lidocaine postconditioning induced a significant decrease in the level of MDA of lung tissue[(7. 03±1.17) μmol/L] compared with ischemia reperfusion group [(8.77±1.42) μmol/L] (P<0.05). Lidocaine postconditioning resulted in a lower level of TNF-α [(1. 69±0.34) μg/L] than that of I-R group [(2. 52±0. 54) μg/L] (P < 0. 05). Microscopic examination showed that lidocaine postconditioning could decrease the level of edema of left lung and accumulation of neutro-phils. Conclusion Lidocaine postconditioning exerts a protective effect on pulmonary ischemia-reperfusion injury administered in the beginning of reperfusion. The effect may be explained by to the antioxidant effect and the suppression of expression of TNF-α.

Objective To investigate the effect of artifictal circadian rhythm of melatonin on the postoperative cellular immune function in patients undergoing gynecological operation Methods Eighteen ASA Ⅰ or Ⅱ patients,aged 25-50 yr,weighing 45-80 kg,scheduled for elective gynecological operation,were randomly divided into 3 groups (n =6 each):control group (group C),placebo control group (group P) and melatonin group (group M).In group M.melatonin 6 mg was given orally at 10 min before lights-out (21:00) on 1 day before operation,on the day of operation and on 1 day after operation,while placebo was given orally instead of melatonin in group P.The operation was performed under epidural anesthesia.Patient-controlled epidural analgesia with ropivacaine was used for postoperative analgesia.VAS score was maintained ＜ 5.Blood samples were collected from the peripheral vein at 1 day before operation (baseline),the end of operation and 1 day after operation to measure CD4+,CD8+ and CD3+ cell count by flow cytometry.The ratio of the number of CD4+ cells to the number of CD8+ cells was calculated.Results There were no significant differences in the number of CD4+,CD8+ and CD3 + cells and ratio of the number of CD4 + cells to the number of CD8 + cells between groups C,P and M (P ＞0.05).Conclusion Artificial circadian rhythm of melatonin exerts no influence on the postoperative cellular immune function in patients undergoing gynecological operation.

Objective To investigate the alleviative effects of lidocaine postconditioning on pulmonary injury following ischemia reperfusion.Methods Seventy-two adult SD rats were randomized to 4 groups:sham group,ischemia-reperfusion(I-R) group,ischemic postconditioning(IPC) group and lidocaine postconditioning group. The pulmonary ischemia-reperfusion model was established by occlusion of the left hilum of lung for 45 min and the reperfusion was taken by removing the clamp for 2 h. At the moment of reperfusion,lidocaine 4 mg/kg was injected as a priming dose following a continuous rate of 4 mg/(kg?h). PaO2,TNF-?,W/D of left lung,the level of MDA of left lung tissue were measured. At the end of reperfusion left lung was removed for microscopy. Results After reperfusion PaO2 of lidocaine group was much higher than that of I-R group(P

Objective:To compare the efficacy and safety of Shikani ( S) optical stylet and Macintosh (M) laryngoscope for double-lumen endotracheal tube intubation .Methods:In the study, 60 patients undergoing elective thoracic surgery were randomly allocated to group S ( n=30 ) and group M ( n=30 ) . After general anesthesia induction , the patients in group S and group M were intubated double-lumen en-dotracheal tube ( DLT) by Shikani optical stylet ( SOS) and macintosh laryngoscope respectively .Intuba-tion time, intubation attempts , cuff broken and oral mucosal or dental injury were recorded;Blood pres-sure and heart rate at baseline ( T0 ) , at the time of intubaiton onset ( T1 ) , 1 minute after intubaiton (T2), 3 minutes after intubation (T3) and 5 minutes after intubation (T3) were also recorded;Hoarse-ness and throat sore of the patients 24 hours after surgery were evaluated .Results:The intubaiton time with the SOS was faster than with the Macintosh [(37.4 ±9.7) s vs.(43.9 ±13.7) s, P=0.039] and the first attempt success rate (87%vs.80%, P=0.488) did not differ between the groups; No tube cuff broke in both the groups;Group S had fewer patients who suffered oral mucosal or dental injury than group M (8 vs.2, P=0.038);The blood pressure and heart rate at T0,T1,T2,T3 and T4 did not differ between the groups;Throat sore(7 vs.10, P=0.390) and hoarseness (5 vs.7, P=0.519) incidence did not differ between the groups .Conclusion:By comparison of the Macintosh laryngoscope , the SOS provides faster DLT intubation and causes less oral Mucosal or dental injury .

Objective To confirm the efficacy of the “Hourglass Pattern”of ultrasound-guided fascia iliaca compartment block (FICB). Methods Approved by the medical ethics committee,we selected 30 patients undergoing selective total hip arthroplasty (THA ) in our hospital between January and May 2014.Before neuraxial anesthesia,ultrasound-guided FICB was performed.After identification of the “Hourglass Pattern”(internal oblique muscle and the sartorius muscle),a catheter was inserted. The sheath between the fascia iliaca and the iliacus muscle was distended with 40 ml of 0.2% ropivacaine,and then a continuous infusion of ropivacaine at a rate of 10 ml /h was administered for 48 h.Loss of sensation in the distribution areas of the femoral nerve and lateral femoral cutaneous nerve within 30 min was recorded.Patients were interviewed at 4 h,8 h,12 h,24 h,36 h and 48 h after block for pain intensity.Patients’ satisfaction scores at 48 h after block and the occurrence of adverse events (infection,local anesthetic toxicity,hemorrhage and hematoma)was recorded. Results The successful rate of the block was 100% without any adverse events.The median of numerical rating pain scale (NRPS)was below 4 points at 4 h,8 h,12 h,24 h,36 h and 48 h after block,and the patients’satisfaction score was (8.0 ±0.9 )points at 48 h after block.No adverse events occurred. Conclusions Ultrasound-guided FICB by using the “Hourglass Pattern”technique can offer effective analgesia after THA.It’s a safe method and can be easily performed.

Objective To investigate the relationship between bispectral index (BIS) and cerebrospinal fluid (CSF) concentrations of propofol or effect-site concentrations during target-controlled infusion (TCI) of propofol and evaluate the accuracy of the infusion system targeting at effect-site concentration.Methods Twelve healthy mongrel dogs weighing (17.04? 1.53) kg were anesthetized with intramuscular ketamine 5 mg?kg-1 followed by enflurane inhalation. A catheter was inserted into subarachnoid space and advanced to the base of skull for the collection of CSF. BIS, hemodynamics and PETCO2 were monitored continuously during the experiment. Target effect-site propofol concentration was set at 3 ?g?ml-1 and infusion was continued for 15 min. CSF was collected at 1, 3, 5, 10, 15, 20, 30, 45 and 60 min after infusion was started for determination of propofol concentration by high performance liquid chromatography with fluorescence detection. Results The equilibrium between predicted plasma and effect-site concentration was reached at 10.9 min and the target effect-site concentration was maintained at 3 ?g?ml-1 .The peak CSF concentration of propofol was (0.29? 0.14)?g?ml-1 .CSF concentrations were much lower than the effect-site concentrations at all sampling times (about 18.7% of the effect-site concentration on average) . BIS was consistent with the CSF concentrations of propofol. Both of them reached the lowest or peak values at 5 min after infusion was started, while the peak effect-site concentration was reached relatively later. BIS was found to be better correlated with CSF concentration (? = 0.9195) than with the effect-site concentration (? = 0.554) . The dogs developed hypotension as expected but no other severe adverse effect was observed. Conclusion The inconsistency of BIS with effect-site concentration during TCI of propofol may result from its pharmacokinetic parameters. Good correlation between BIS and CSF concentration indicates that CSF concentration can reflect the pharmacokinetic profileof propofol at effect-site more accurately than the plasma concentration during TCI of propofol targeting at effect-site concentration.

Objective To investigate the clinical features of multiple endocrine neoplasia ( MEN) associated with pheochromocytoma and anesthetic management during perioperative period. Methods Medical records of 12 patients who were operated upon for MEN associated with pheochromocytoma in our hospital from April 1977 to April 2001 were reviewed retrospectively. The demographic data, clinical manifestation, family history, biochemical examinations, type of MEN, the order of different surgical procedures for patients who had multiple operations and changes in hemodynamics were collected and analyzed. Results The 12 patients accounted for 5.6% (12/213) of the patients with pheochromocytoma admitted in the same period. Nine of the 12 patients had a diagnosis of MEN Ⅱa (Sipple syndrome) and three mixed MEN. Four patients with MEN type II a had a positive familial history. Five patients with other coexistent endocrine disorders underwent the excision of pheochromocytoma first, and only two of them had hypertensive symptoms when they were admitted. Seven patients without a history of hypertensive episodes received surgical treatment for pheochromocytoma as a second operation. The excision of pheochromocytoma was performed under general anesthesia ( in 8 patients ) or epidural anesthesia (in 4 patients). Marked hemodynamic fluctuations were recorded in 8 patients. There was no death.Conclusion Pheochromocytoma associated with other endocrine disorders in MEN may manifest itself as the main clinical symptom or most frequently as an occult tumor. Recognition of this feature is of importance to the improvement of diagnosis and treatment of both pheochromocytoma and MEN.