不同浓度罗哌卡因用于全产程硬膜外分娩镇痛的疗效观察

目的比较不同浓度罗哌卡因用于不同产程硬膜外分娩镇痛的效果。方法选择要求硬膜外分娩镇痛的初产妇360例,随机分为3组(n=120)。所有患者在完成硬膜外腔置管后,硬膜外腔注射负荷剂量局麻药(0.1%罗哌卡因+2μg/ml芬太尼),阻滞平面达T_(10)后接PCA泵行PCEA。A组PCA采用0.1%罗哌卡因+2μg/ml芬太尼,宫口开全时停止PCA。B组PCA采用0.1%罗哌卡因+2μg/ml芬太尼全产程镇痛。C组PCA采用0.08%罗哌卡因+2μg/ml芬太尼全产程镇痛。观察产妇镇痛前(T_0)、镇痛后1小时(T_1)、2小时(T_2)、3小时(T_3)、宫口开全时(T_4)、分娩时(T_5)、会阴部修复时(T_6)VAS评分;采用Bromage评分评价运动阻滞程度;记录产程时间、镇痛时间、分娩方式、新生儿Apgar评分、满意度评分及不良反应的发生情况。结果与T_0时比较,B、C两组产妇T_1~T_6时点VAS评分较低,A组T_1~T_5时点VAS评分较低(P0.05)。与A组比较,B、C两组产妇T_6时点VAS评分较低;产妇对分娩镇痛效果满意度较高(P0.05)。3组产妇第一产程时间、第一产程镇痛时间、第二产程时间、分娩方式、新生儿Apgar评分、Bromage评分及不良反应差异无统计学意义(P0.05)。结论全产程硬膜外分娩镇痛效果优于第一产程分娩镇痛,而0.08%罗哌卡因复合芬太尼用于全产程分娩镇痛具有较好的效果与安全性。     

罗比卡因硬膜外腔阻滞在分娩镇痛中的应用

目的　观察不同浓度罗比卡因应用于分娩镇痛的安全性与有效性 ,并与布比卡因进行比较。方法　选择足月、单胎、头位初产妇 88例 ,ASAⅠ～Ⅱ级 ,其中自愿接受分娩镇痛 48例 ,随机分为四组 (n =12 ) :(1) 0 2 %布比卡因 (B组 ) ;(2 ) 0 2 %罗比卡因 (R组 ) ;(3) 0 1%罗比卡因 +芬太尼 2 μg/ml间断注药 (RF组 ) ;(4) 0 1%罗比卡因 +芬太尼 2 μg/ml持续用药 (RFC组 )。对照组 40例未行分娩镇痛。于产程进展宫口开至 3cm时 ,行硬膜外腔穿刺置管 ,首次剂量 8～ 12ml。B组、R组和RF组按需追加 5～ 8ml/次 ,RFC组在给首量后半小时 ,用输液泵将维持量以 5～ 7ml/h持续硬膜外腔输注至宫口开全停药。结果　行分娩镇痛各组产妇用药后VAS评分均明显降低 ,感觉减退平面均在T10 以下 (T10 ～S4 ) ,Bromage评分均为 0级。罗比卡因各组宫口扩张速率和胎头下降速率较快。对产程和分娩方式和母胎均无明显影响。联合用药可减少局麻药用量。结论　罗比卡因应用于分娩镇痛对产程影响较小 ,联合用药更加优越 ,持续输注实施简便     

罗哌卡因复合芬太尼用于可行走硬膜外分娩镇痛的可行性

目的 探讨0．075％罗哌卡因或布比卡因与芬太尼2μg/ml的混合液用于可行走硬膜外分娩镇痛的可行性。方法 60例初产妇随机分为三组：A组（n＝20）0．075％罗哌卡因＋芬太尼2μg/ml;B组（n＝20）0．075％布比卡因＋芬太尼2μg/ml;C级（n＝20）为对照组。采用双盲法进行视觉模拟疼痛评分（VAS）和行走功能的评定。记录各组产妇的生命体征、胎心率（FHR）、产程时间、分娩方式、催产素用量以及新生儿Apgar评分和脐静脉血气分析,并测定用药前和宫口开全时母体血清皮质醇浓度。结果 A、B两组产妇均获得良好镇痛效果,镇痛后A组所有产妇均能下床行走和自主排尿,而B组仅70％产妇能下床行走和自主排尿,两组比较有显著性差异（P＜0．05）;A、B两组第一产程末血清皮质醇浓度明显低于C组（P＜0．05）。产程时间、分娩方式和新生儿Apgar评分各组间均无差异（P＞0．05）。结论 0．075％罗哌卡因和芬太尼2μg/ml的混合液有效安全地用于可行走硬膜外分娩镇痛。     

低背景剂量联合大剂量PCA在产妇硬膜外分娩镇痛中的应用

目的观察在持续输注联合硬膜外自控给药模式下低背景剂量持续输注联合大剂量PCA的参数设置对分娩镇痛临床效果的影响。方法选择自愿接受分娩镇痛足月、单胎和头位初产妇120例,年龄25~35岁,体重58~86kg,ASAⅠ或Ⅱ级,随机分为两组:常规组(A组)和低背景剂量组(B组)。在宫口扩张2~3cm时采用硬膜外分娩镇痛。每组均事先配置硬膜外注射混合液0.1%罗哌卡因+2μg/ml芬太尼100ml。A组为常规组,背景剂量6ml/h,PCA 5ml,间隔40min;B组为低剂量组,背景剂量2ml/h,PCA 10ml,间隔为40min。记录产妇镇痛前、镇痛后10min、30min、1h、2h、宫口开全时和分娩时VAS评分及改良Bromage评分;记录PCA追加次数;记录爆发痛例数;记录硬膜外混合液的用量;记录镇痛时间、产程时间、分娩方式;记录不良反应的发生情况和新生儿Apgar评分。结果镇痛期间两组产妇VAS评分差异无统计学意义;接受镇痛期间B组混合液用量(40.5±7.5)ml;明显少于A组(60.3±12.0)ml(P0.05);B组PCA实际追加次数(1.6±0.9)次明显少于A组(3.0±1.8)次(P0.05)。两组产妇的产程、镇痛时间、爆发痛例数、不良反应发生率、产妇分娩方式和新生儿Apgar评分差异无统计学意义。结论采用低背景剂量(2ml/h)联合大剂量PCA(10ml,间隔40min)的硬膜外自控镇痛参数设置不仅没有降低镇痛效果,还可减少硬膜外腔用药总量。     

产妇产程潜伏期罗哌卡因混合舒芬太尼硬膜外分娩镇痛的效果

目的观察产妇产程潜伏期和活跃期罗哌卡因混合舒芬太尼硬膜外分娩镇痛的效应，评价潜伏期镇痛的可行性。方法120例无产科及硬膜外阻滞禁忌症的单胎孕初产妇，随机分为2组。潜伏期组（L组）：当进入产程、但宫口〈3cm进行镇痛；活跃期组（A组）：当宫口≥3cm进行镇痛。硬膜外穿刺成功后，两组分别单次给予0．1％、0．15％罗哌卡因与0．5μg／ml舒芬太尼混合液10—15ml。30min后行硬膜外自控镇痛，药物为0．1％罗哌卡因和0．5μg／ml舒芬太尼的混合液，PCA量6ml，锁定时间20min（L组）、15min（A组）。行VAS评分和运动神经阻滞分级，记录产后产妇的不良反应，对新生儿行Apgar评分。结果两组镇痛后VAS评分均降低，与A组比较，L组镇痛前VAS评分降低，镇痛后20、30min VAS评分升高，下肢麻木发生率升高，镇痛前催产素使用率及镇痛后催产素追加率降低（P〈0．05）。两组产程、剖宫产率和器械助产率及镇痛满意度的优良率差异无统计学意义（均超过95％）（P〉0．05）。结论产妇产程潜伏期0．1％罗哌卡因混合0．5μg／ml舒芬太尼硬膜外分娩镇痛安全、有效。     

产妇分娩时舒芬太尼或芬太尼混合罗哌卡因病人自控硬膜外镇痛的效应

目的比较产妇分娩时舒芬太尼或芬太尼混合罗哌卡因病人自控硬膜外镇痛(PCEA)的效应。方法无产科及硬膜外阻滞禁忌证的阴道分娩单胎初产妇120例,随机分为2组(n：60)：舒芬太尼混合罗哌卡因PCEA组(S组)和芬太尼混合罗哌卡因PCEA组(F组)。当产妇宫口开至3cm时,L_(2,3)间隙硬膜外穿刺置管,S组硬膜外注射0．15%罗哌卡因和0．5μg/ml舒芬太尼混合液试验剂量5 ml,随后追加上述混合液10 ml,30min后以0．1%哌卡因和0．5μg/ml舒芬太尼的混合液行PCEA；F组混合液中以2μg/ml芬太尼替代0．5μg/ml舒芬太尼,其他用药情况均与S组同。两组PCA剂量为6 ml,锁定时间为15 min。记录产妇视觉模拟疼痛评分(VAS)、下肢运动神经阻滞程度、生命体征、产程、分娩方式、不良反应及新生儿Apgar评分。结果两组镇痛期间VAS评分均降低,S组镇痛20～60 min VAS评分均低于F组。两组镇痛起效时间、达最高镇痛平面的时间、最高绝对平面、PCA实际按压次数、有效按压次数差异均无统计学意义。S组皮肤瘙痒的发生率高于F组,舒芬太尼、芬太尼用量分别为16±8、(70±28)μg,比率为1：4．4。两组产程和分娩方式构成比差异无统计学意义。结论产妇分娩时等效剂量的舒芬太尼或芬太尼混合罗哌卡因PCEA均可提供良好的镇痛效果。     

硬膜外罗哌卡因复合舒芬太尼或芬太尼用于潜伏期分娩镇痛

目的探讨硬膜外罗哌卡因复合舒芬太尼或芬太尼用于潜伏期分娩镇痛的镇痛效果。方法选择自愿要求分娩镇痛的初产妇120例,随机均分为罗哌卡因+舒芬太尼0.5μg/ml组(S组)和罗哌卡因+芬太尼1.5μg/ml组(F组)。潜伏期宫口开大2cm,规律宫缩时开始硬膜外分娩镇痛,背景输注10ml/h,单次PCA剂量5ml,锁定时间30min。观察记录各时点疼痛VAS评分、产程时间、分娩方式、新生儿Apgar评分、产后出血量、缩宫素使用情况、产妇满意度及不良反应等。结果宫口开大3、5、8、10cm时S组疼痛VAS评分明显低于F组(P0.05);两组间产程时间、剖宫产率和器械助产率差异无统计学意义;两组新生儿出生5min时Apgar评分、缩宫素使用率、产后出血量差异无统计学意义;两组头晕、恶心呕吐、皮肤瘙痒等不良反应发生率差异无统计学意义。结论舒芬太尼复合罗哌卡因用于潜伏期硬膜外分娩镇痛安全有效,不良反应少。     

不同浓度的罗比卡因用于可行走式分娩镇痛

目的　比较不同浓度的罗比卡因用于分娩镇痛的效果。方法　 90例初产妇随机分成三组行分娩镇痛 ,Ⅰ组为 0 0 75 %罗比卡因加 1μg/ml芬太尼 ,Ⅱ组为 0 1%罗比卡因加 1μg/ml芬太尼 ,Ⅲ组为 0 12 5 %罗比卡因加 1μg/ml芬太尼。观察指标有首剂量、起效时间、PCA次数、VAS评分、运动神经阻滞评分、第一、二产程时间、分娩方式等指标 ,全程监测孕妇血压、心率、宫缩以及胎儿胎心。结果　Ⅱ组和Ⅰ组相比较 ,下肢运动神经阻滞程度无显著差异 ,但孕妇镇痛良好率明显高于Ⅰ组 (P <0 0 1) ,满意率也明显高于Ⅰ组 (P <0 0 5 ) ,产程时间和分娩方式没有显著差异 ;Ⅱ组和Ⅲ组比较 ,镇痛效果、产程时间、分娩方式均无显著差异 ;但Ⅲ组发生轻度运动神经阻滞的比例明显高于Ⅱ组 (P <0 0 5 )。结论　 0 1%罗比卡因加 1μg/ml芬太尼不仅具有良好的镇痛效果 ,而且对运动神经影响轻微 ,是可行走式分娩镇痛较为理想的用药方案。     

罗比卡因硬膜外分娩镇痛的临床研究

目的:研究低浓度罗比卡因病人自控硬膜外镇痛(PCEA)行分娩镇痛的效果.方法:选择109例ASAⅠ～Ⅱ级、头位、单胎足月妊娠的初产妇行PCEA(分娩镇痛组).另选100例条件相仿但不给予硬膜外阻滞的自然分娩产妇为对照组.分娩镇痛组给予0.1%罗比卡因+芬太尼(1μg/ml),PCEA基础注药速率为6ml/h,冲击量为2ml,锁定时间为10分钟.进行视觉模拟镇痛评分(VAS)和下肢运动神经阻滞评分(MBS).记录产程时间、生产方式.监测胎儿心率(FHR)、新生儿Apgar评分和SpO2.结果:分娩镇痛组用药后15～30分钟均感到无痛或只感到轻度可耐受的疼痛(VAS评分0.6±0.8).分娩镇痛组产妇MBS在镇痛前后无统计学差异(P＞0.05),所有产妇均能下床活动.分娩镇痛组产妇第一产程时间为464.9±173.5分钟,短于对照组第一产程时间(P＜0.05).分娩镇痛组第二产程时间为48.4±21.8分钟,对照组为46.7±20.6分钟,两组无统计学差异(P＞0.05).分娩镇痛组新生儿1、5分钟Apgar评分和SpO2与对照组无统计学差异(P＞0.05).结论:低浓度罗比卡因分娩镇痛效果确切,对运动神经阻滞轻,不影响产程及新生儿,是目前分娩镇痛较理想的方法.     

腰麻-硬膜外联合阻滞应用于分娩镇痛的临床观察

目的　探讨腰麻 硬膜外联合阻滞 (CSEA)用于分娩镇痛的效果及对产程、母婴的影响。方法　选择 2 3 7例ASAⅠ～Ⅱ级的足月初产妇行分娩镇痛为观察组 ;另选 2 0 0例条件相仿但不给分娩镇痛为对照组。观察组在蛛网膜下隙注入布比卡因 2mg和芬太尼 2 0 μg ;90分钟后硬膜外给予0 12 5 %罗比卡因和 2 μg/ml芬太尼行硬膜外病人自控镇痛 (PCEA)。其基础注药速度为 6ml/h ,冲击量为 2ml,锁定时间为 10分钟。用视觉模拟评分 (VAS)和下肢运动神经阻滞评分 (MBS)评估镇痛、阻滞效果 ,观察记录产妇的生命体征、产程时间、生产方式及新生儿Apgar评分。 结果　观察组产妇生命体征平稳 ,用药后 10分钟 99 2 %的产妇感到无痛 [VAS评分为 ( 0 0 4± 0 11)分 ],仅 0 8%的产妇镇痛不全。与镇痛前比较 ,观察组产妇MBS在腰麻后 10分钟显著增加 ,直至腰麻后 90分钟。观察组活跃期时间为 ( 96 3 4± 62 77)分钟 ,短于对照组 (P <0 0 1)。观察组第二产程时间 ( 5 3 15±2 5 70 )分钟 ,对照组为 ( 5 0 83± 2 4 81)分钟 (P >0 0 5 ) ;观察组新生儿出生后 1、5分钟Apgar评分、生产方式与对照组比较亦无统计学差异。结论　CSEA用于分娩镇痛效果确切 ,对运动神经阻滞轻 ,不影响产程及新生儿     

Obstetric analgesia: peridural analgesia versus combined spinal and peridural analgesia]

OBJECTIVE: To compare the analgesic efficiency, side effects and obstetrical repercussions of epidural analgesia (EP) and combined spinal-epidural analgesia (CSE). STUDY DESIGN: Prospective, randomized, double or single-blind studies as required, approved by the ethical committee of the institution. PATIENTS: The study included 80 parturients, in active labour with a singleton in vertex presentation and a cervical dilatation of 3 cm or less, randomly allocated to receive either EP (n = 40) or CSE (n = 40). METHOD: In the EP group, sufentanil (20 micrograms) and 0.25% bupivacaine (6-8 mL) were injected into the epidural space. In those of the CSE group, sufentanil (10 micrograms) was first injected into the subarachnoid space, followed by an epidural injection of the same agents at the same quantities as for the EP group. Additional analgesia was obtained in both groups by top-ups of 6-8 mL of 0.25% bupivacaine at the request of the patients. Analgesia, course of labour, obstetrical outcome, and neonatal status were assessed. Statistical analysis was performed using Anova, chi 2 analysis, Yates' correction or Fisher's exact test, with a P < 0.05 considered as significant. RESULTS: Both groups had similar demographic and obstetric data. The onset of analgesia was more rapid in CSE group (8 +/- 11 min vs. 12 +/- 7 min, P < 0.05), however the duration was similar. Technical incidents were more frequent in the CSE group (30% vs. 7%, P < 0.05). The technique of analgesia did not influence the bupivacaine amounts required for its maintenance. The incidence of adverse effects were comparable with the exception of vertigo, which was more frequent in the EP group (57% vs. 28%, P < 0.05). The first stage of labour was increased by 30% in the CSE group (281 +/- 130 min vs. 216 +/- 97 min, P < 0.05), without significant prolongation of labour length. Durations of second stage and expulsion were similar in both groups, despite the administration of a lower dose of bupivacaine in the CSE group (33 +/- 17 mg vs. 46 +/- 12 mg, P < 0.05). The rates of instrumental deliveries and Caesarien sections were comparable. The Apgar scores were satisfactory at 5 min. CONCLUSION: In the early phase of labour, the CSE technique using intrathecal sufentanil has no significant benefit when compared to the EP technique using bupivacaine and sufentanil. In the CSE group, technical incidents were more frequent and the length of the first stage of labour was increased.     

Postoperative analgesia

Postoperative analgesia both by drugs and regional techniques is reviewed. In the United Kingdom in the last 25 years or more there has been little advance on either front. Some marginal improvement in regard to drugs might be brought about by better education of both doctors and nurses and better patient contact. Extradural analgesia and intercostal block do not offer a complete solution, though a judicious increase in the use certainly of the former might be beneficial. The problem awaits a radical new approach.     

Patient-controlled analgesia

Two modern patient-controlled analgesia pumps have been evaluated in the laboratory and in clinical use. Both machines generally performed satisfactorily and patients achieved good pain relief from self-administered morphine. The relative merits of the two pumps are discussed and although the on demand analgesic computer is preferred, a substantial investment of time on the ward is required to provide continuous patient-controlled analgesia.     

Postoperative analgesia

Pain is a complex experience consisting of sensory, affective, behavioural and physiological components. Pain management is therefore best achieved through an approach which acknowledges the complex interaction between biological, psychological and sociocultural factors. Effective pain management requires preoperative patient engagement and education in order to manage expectations and a structured inpatient service to facilitate evidence-based postoperative pain management and continuous staff education. Multimodal postoperative analgesia, built on an opioid-sparing ethos, is an essential component of perioperative pain management. Effective pain management facilitates early mobilization and a reduction in respiratory and cardiac complications and reduces the stress response to surgery which in turn improves wound healing and recovery. Inadequate pain control can lead to morbidity and mortality including prolonged hospital stays and the development of chronic postoperative pain.     

Patient-controlled analgesia

A patient received a massive overdose of papaveretum intravenously (estimated to be 180 mg) when the glass syringe of a patient-controlled analgesia machine disengaged from the drive mechanism. She was successfully resuscitated. The pump, on loan from the supplier, had passed a brief evaluation by the infusion pump test house designated by the Medical Devices Directorate of the Department of Health; it has since been withdrawn. It is recommended that patient-controlled analgesia equipment should be placed at or below patient heart level. The Department of Health is called on to institute a full, independent evaluation scheme for patient-controlled analgesia equipment.     

Patient-controlled interscalene analgesia versus patient-controlled intravenous analgesia in postoperative analgesia after upper extremity surgery

The effectiveness of patient-controlled interscalene analgesia (PCISA) and patient-controlled intravenous analgesia (PCIVA) in the management of postoperative pain in 36 patients was studied. The general anesthetic technique was standardized. After surgery, all patients received 2 mg intravenous morphine. The patients were then randomized to receive either PCISA or PCIVA. The PCISA group received an interscalene block with 20 ml of 1% lidocaine. A catheter was introduced within the interscalene sheath and 20 min after the initial block, patients received a continuous infusion of 0.125 bupivacaine at rate of 4 ml/h supplemented by a bolus dose of 3 ml with a 15-min lockout time. PCIVA was given as a 1 mg morphine bolus and a 7-min lockout time. Pain relief was regularly assessed using a visual analog scale. Side effects and patient satisfaction were noted. The study period ended 48 h after the operation. Pain relief was significantly better controlled in the PCISA group 6, 12, 24, and 30 h after the operation (P<0.05). At 36, 42, and 48 h, no significant difference in pain score between the two groups was observed. Patient satisfaction was greater in the PCISA group (P<0.05). Vomiting and pruritus were observed more frequently in the PCIVA group (P<0.05). No major complications occurred in any of the study patients. The use of the PCISA technique was uncomplicated and provided better pain relief than PCIVA in postoperative analgesia.     

Postoperative analgesia

Pain is a complex experience consisting of sensory, affective, behavioural and physiological components. Pain management is therefore best achieved through an approach which acknowledges the complex interaction between biological, psychological and sociocultural factors. Effective pain management requires preoperative patient engagement and education in order to manage expectations and a structured inpatient service to facilitate evidence-based postoperative pain management and continuous staff education. Multimodal postoperative analgesia, built on an opioid-sparing ethos, is one component of postoperative pain management and is essential for achieving patient satisfaction and enhanced recovery. Effective pain management facilitates early mobilization and a reduction in respiratory and cardiac complications, reducing the stress response to surgery in turn improving wound healing and recovery. Inadequate pain control can lead to higher morbidity and mortality, prolonged hospital stays and the development of chronic postoperative pain.