不同剂量右美托咪定复合罗哌卡因胸椎旁神经阻滞在非插管胸腔镜手术中的比较

目的比较不同剂量右美托咪定复合罗哌卡因胸椎旁神经阻滞在非插管胸腔镜手术中的效果。方法择期行胸腔镜肺大泡切除术的患者114例,男90例,女24例,年龄25～60岁,BMI25 kg/m~2,ASAⅠ或Ⅱ级,随机分为四组。麻醉诱导前行胸椎旁神经阻滞,C组注入0.375%罗哌卡因20 ml, D1、D2、D3组分别注入右美托咪定0.5、1.0、2.0μg/kg复合0.375%罗哌卡因20 ml。记录感觉阻滞起效时间和持续时间;入室时(T_0)、注药后30 min(T_1)、手术开始时(T_2)、手术开始后30 min(T_3)的RR、PaO_2和PaCO_2;术毕全麻药的用量;术中低血压、心动过缓和使用麻黄碱与阿托品的情况。结果与C、D1组比较,D2、D3组感觉阻滞起效时间明显缩短(P0.05),持续时间明显延长(P0.05),T_2、T_3时PaCO_2明显降低(P0.05),RR、PaO_2明显升高(P0.05),术毕丙泊酚和瑞芬太尼的用量明显减少(P0.05);D3组心动过缓和低血压的发生率明显高于其他三组(P0.05)。结论右美托咪定1.0μg/kg复合罗哌卡因行胸椎旁神经阻滞可缩短感觉阻滞起效时间,延长持续时间,减少全麻药用量,无明显血流动力学不良反应发生。     

丙泊酚-雷米芬太尼静脉麻醉联合罗哌卡因硬膜外神经阻滞用于胃癌手术的苏醒期观察

丙？白酚-雷米芬太尼静脉全身麻醉苏醒迅速,但易出现术后疼痛及躁动现象。硬膜外神经阻滞可提供良好的镇痛,减轻患者应激反应,减少全麻药用量。本研究观察采用丙泊酚-雷米芬太尼静脉麻醉联合低浓度罗哌卡因硬膜外神经阻滞对胃癌手术患者苏醒期的影响。     

罗哌卡因复合地塞米松胸椎旁神经阻滞用于Ivor-Lewis食管癌根治术的效果

目的观察超声引导下罗哌卡因复合地塞米松胸椎旁阻滞(TPVB)在Ivor-Lewis食管癌根治术中的应用效果。方法选择择期行Ivor-Lewis食管癌根治术患者60例,男29例,女31例,40～75岁,ASAⅠ—Ⅲ级。采用数字表法将患者随机分为两组:单纯罗哌卡因组(R组)和罗哌卡因复合地塞米松组(RD组),每组30例。全麻诱导前行超声引导下TPVB,R组采用0.5%罗哌卡因15 ml加生理盐水3 ml, RD组采用0.5%罗哌卡因15 ml加地塞米松0.15 mg/kg(用生理盐水稀释到3 ml)。记录镇痛持续时间、术后48 h内镇痛泵有效按压次数及补救镇痛例数,记录术后2、4、8、12、24、48 h静息和咳嗽时VAS疼痛评分,记录术后24 h内不良反应以及术后3个月慢性疼痛的发生情况。结果 RD组镇痛持续时间明显长于R组,术后48 h内镇痛泵有效按压次数明显少于R组,术后2、4、8、12、24 h静息和咳嗽时VAS疼痛评分明显小于R组(P0.05)。两组补救镇痛率和术后24 h内不良反应发生率差异无统计学意义。RD组术后3个月慢性疼痛发生率明显低于R组(P0.05)。结论与单纯罗哌卡因比较,罗哌卡因复合地塞米松可延长食管癌根治术患者胸椎旁神经阻滞持续时间,增强镇痛效果,降低食管癌根治术患者术后慢性疼痛发生率。     

罗哌卡因双侧胸椎旁神经阻滞联合全身麻醉用于非体外循环冠脉搭桥手术20例

目的观察全身麻醉(全麻)复合罗哌卡因单次双侧胸椎旁神经阻滞用于非体外循环冠脉搭桥(OPCAB)手术的麻醉效果。方法将40例择期行OPCAB的患者采用随机数字表法随机分为单纯全麻组(A 组,n＝20)和全麻复合罗哌卡因双侧胸椎旁神经阻滞组(B组,n＝20),记录两组患者在术中发生异常血流动力学的频数,以及心血管药物的使用量,并记录术中及术后镇痛舒芬太尼的用量及术后气管导管保留时间和重症监护室(ICU)停留时间。结果B组有2例因椎旁阻滞效果不符合要求未纳入之后研究;与A组比较,B组术中发生高血压的频数明显减少(P＜0.05),而术中尼卡地平的使用量也随之减少(P＜0.05),B组患者术中及术后舒芬太尼的用量均明显减少(P＜0.01或P＜0.05),术后气管导管保留时间及ICU停留时间也缩短(P＜0.05)。结论全麻复合罗哌卡因单次双侧椎旁阻滞用于OPCAB手术有利于维持术中循环稳定,减少麻醉镇痛药物用量,并有利于患者术后早期恢复。     

右美托咪定复合罗哌卡因胸椎旁神经阻滞对胸腹腔镜联合食管癌根治术术后恢复质量的影响

目的探讨右美托咪定复合罗哌卡因胸椎旁神经阻滞(TPVB)对胸腹腔镜联合食管癌根治术患者术后恢复质量的影响。方法选择2020年6—12月全麻下择期行胸腹腔镜联合食管癌根治术的患者60例,男32例,女28例,年龄50～70岁,BMI 20～25 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:右美托咪定复合罗哌卡因TPVB组(TD组)和罗哌卡因TPVB组(TS组),每组30例。麻醉诱导前15 min,两组分别在超声引导下行右侧T_6水平椎旁神经阻滞,TD组注入右美托咪定1μg/kg和0.375%罗哌卡因的混合液20 ml, TS组注入0.375%罗哌卡因20 ml。两组麻醉诱导和麻醉维持方法一致,术毕均实施PCIA。采用QoR-40量表评价患者术前1 d、术后3 d和术后1个月的恢复质量。分别在麻醉诱导后5 min、进胸时和术后24 h采集患者静脉血2 ml,检测血浆IL-6、IL-8浓度。记录手术时间、麻醉时间、术中丙泊酚和瑞芬太尼用量、术后4、8、12、24 h静息和运动时VAS疼痛评分、术后24 h补救镇痛例数、术后并发症发生情况。结果与术前1 d比较,术后3 d TS组QoR-40量表评分明显降低(P0.05)。与麻醉诱导后5 min比较,进胸时、术后24 h TD组和TS组血浆IL-6,IL-8浓度均明显升高(P0.05)。与TS组比较,TD组术后3 d、1个月时QoR-40量表评分明显增高(P0.05),进胸时、术后24 h血浆IL-6,IL-8浓度均明显降低(P0.05),术中瑞芬太尼用量明显减少(P0.05),术后4、8、12、24 h静息和运动时VAS疼痛评分明显降低(P0.05),术后24 h补救镇痛例数明显减少(P0.05)。两组肺部感染及肺不张发生率差异无统计学意义。结论右美托咪定1μg/kg复合罗哌卡因胸椎旁神经阻滞可以减轻胸腹腔镜联合食管癌根治术患者术后疼痛,减轻围术期手术炎症反应,减少术中镇痛药物用量,提高患者术后恢复质量。     

神经刺激仪引导胸椎旁神经阻滞用于乳腺区段切除术患者的麻醉效果

目的 评价神经刺激仪引导胸椎旁神经阻滞用于乳腺区段切除术患者的麻醉效果.方法 择期乳腺区段切除术女性患者50例,年龄18～64岁,BMI＜24 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其随机分为2组(n=25):胸段硬膜外阻滞组(A组)和神经刺激仪引导下胸椎旁神经阻滞组(B组).A组行T3.4间隙硬膜外穿刺,硬膜外腔注射0.5％罗哌卡因7～10 ml;B组在神经刺激仪引导下行T4椎旁神经穿刺,注射0.5％罗哌卡因25 ml.记录围术期低血压和心动过缓等心血管不良事件和呼吸抑制的发生情况.记录术中寒战、胸闷、呼吸困难及术后恶心、呕吐等不良反应的发生情况.采用针刺法确定术侧阻滞范围:评价麻醉效果.结果 与A组比较,B组术中寒战、胸闷、呼吸困难及术后恶心、呕吐的发生率降低(P＜0.05).2组均未发生心血管不良事件.2组患者术侧阻滞范围差异无统计学意义(p＞0.05),且麻醉效果优良率均为100％.结论 神经刺激仪引导胸椎旁神经阻滞可安全有效地用于乳腺区段切除术患者的麻醉,且其效果优于胸段硬膜外阻滞.     

舒芬太尼局部用药对罗哌卡因胸椎旁神经阻滞半数有效浓度的影响

目的探讨舒芬太尼局部用药对超声引导下胸椎旁阻滞罗哌卡因半数有效浓度(EC_(50))的影响。方法择期行胸腔镜下肺叶切除术的患者42例,男23例,女19例,年龄30～65岁,BMI 18～28 kg/m~2,ASAⅠ—Ⅲ级,在T_(4-5)水平行超声引导下椎旁神经阻滞。采用随机数字表法将患者分为两组:对照组(C组)和观察组(T组)。C组神经阻滞用药为罗哌卡因20 ml;T组神经阻滞用药为罗哌卡因复合舒芬太尼0.6 ug/ml的混合液20 ml。罗哌卡因浓度由上下序贯法确定,起始浓度为0.5%,间隔浓度比值为1.2。若阻滞效果评定为优良,则下一例采用低一级浓度;若阻滞效果评定为差,则下一例采用高一级浓度。研究终点为达到7个上下周期,或者罗哌卡因浓度≤0.1%或≥1%并持续7例。按照Dixion-Massey EC_(50)序贯法计算公式计算罗哌卡因EC_(50)及其95%CI。结果 C组罗哌卡因EC_(50)为0.41%,95%CI为0.39%～0.43%;T组罗哌卡因EC_(50)为0.33%,95%CI为0.31%～0.35%。结论复合舒芬太尼0.6μg/ml局部用药可降低罗哌卡因胸椎旁阻滞的EC_(50)。     

丙泊酚-雷米芬太尼静脉麻醉联合罗哌卡因硬膜外神经阻滞对胃肠手术患者苏醒期的影响

目的探讨丙泊酚-雷米芬太尼静脉麻醉联合低浓度罗哌卡因硬膜外神经阻滞对胃肠手术患者苏醒期的影响。方法将40例ASAⅠ～Ⅱ级择期行腹部手术患者,随机分为联合麻醉组(观察组)和单纯静脉麻醉组(对照组),每组20例。观察2种麻醉方法对患者术毕苏醒期的影响。结果观察组组术后呼吸恢复时间、拔管时间均明显短于对照组。对照组苏醒期躁动明显多于观察组。2组患者均对手术过程完全遗忘。观察组OAA/S评分明显高于对照组。结论丙泊酚-雷米芬太尼静脉麻醉联合低浓度罗哌卡因硬膜外神经阻滞用于结直肠癌手术麻醉,患者术毕呼吸恢复早、苏醒质量高、拔管时间早、术后躁动少、全麻药用量少且无术中知晓出现,值得临床推广应用。     

复方倍他米松复合罗哌卡因胸椎旁阻滞用于胸腔镜术后镇痛的效果

目的 探讨超声引导下复方倍他米松复合罗哌卡因胸椎旁阻滞用于胸腔镜术后镇痛的效果。方法 选择行择期胸腔镜手术患者60例,男41例,女19例,年龄18～60岁,BMI 18～25 kg/m²,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组：复方倍他米松复合罗哌卡因组(B组)和罗哌卡因组(R组),每组30例。两组在麻醉诱导前行超声引导下胸椎旁阻滞,B组注射药物为加入复方倍他米松0.5 ml的0.4%罗哌卡因25 ml, R组注射药物为0.4%罗哌卡因25 ml。两组均采用标准化的支气管插管静脉全麻方案,术后行PCA。记录阻滞起效时间、镇痛持续时间、PCA首次按压时间,术中舒芬太尼、瑞芬太尼、丙泊酚用量,术后2、4、8、12、24、48 h静息和活动时(咳嗽)VAS疼痛评分,术后48 h PCA总按压次数和舒芬太尼补救镇痛例数,术后48 h内呼吸抑制、恶心呕吐、穿刺部位感染、尿潴留等不良反应发生情况。结果 与R组比较,B组阻滞起效时间明显缩短(P<0.05),镇痛持续时间、PCA首次按压时间明显延长(P<0.05)。两组术中舒芬太尼、瑞芬太尼、丙泊酚用量差异均...     

全麻复合硬膜外麻醉及术后硬膜外镇痛对食管癌患者术后T细胞亚群及循环、呼吸的影响

目的探讨静脉全麻复合硬膜外麻醉(CGEA)及患者自控硬膜外镇痛(PCEA)对食管癌患者术后 T 细胞亚群及循环、呼吸的影响。方法选择60例 ASA Ⅰ或Ⅱ级择期行食管癌根治术的患者,随机均分为三组。A 组行 CGEA 及术后 PCEA,B 组行 CGEA 及术后患者自控静脉镇痛(PCIA),C 组行全凭静脉麻醉及术后 PCIA。分别于麻醉前30 min(T_0)、术后4 h(T_1)、1 d(T_2)、2 d(T_3)、3 d(T_4)、7 d(T_5)取外周静脉血2 ml,用流式细胞仪测定 T 淋巴细胞亚群,并观察各时间点循环、呼吸指标以及疼痛、镇静评分。结果三组患者 T_1～T_3时 CD3~ 、CD4~ 、CD8~ 、CD4~ /CD8~ 均明显下降(P<0.05)。B、C 组 RR 在T_1时明显快于 A 组(P<0.05)。T_4时 A 组 T 淋巴细胞亚群恢复至 T_0,B 组和 C 组 T_5时 CD3~ 、CD4~ 、CD8~ 、CD4~ /CD8~ 均基本恢复。结论 CGEA 辅以术后PCEA 可改善食管癌患者术后呼吸、循环功能并减轻免疫功能的抑制。     

超声引导下三点阻滞与椎旁阻滞用于剖腹肝胆手术术后镇痛的比较

目的观察术前给予超声引导下三点法阻滞(低位前锯肌阻滞、肋缘下腹横肌平面阻滞和腹直肌后鞘阻滞)或单侧胸椎旁阻滞对肝胆手术患者术后镇痛及相关围术期转归的影响。方法选择择期右上腹部切口行肝胆手术的患者95例,男69例,女26例,年龄18～65岁,ASAⅠ或Ⅱ级。随机分为三点组(n=48)和椎旁组(n=47)。三点组患者入室后采用0.375%罗哌卡因行超声引导下低位前锯肌阻滞(10 ml)、肋缘下腹横肌平面阻滞(15 ml)复合腹直肌后鞘阻滞(15 ml),椎旁组采用0.375%罗哌卡因20 ml行超声引导下T_(7-9)椎旁阻滞。记录术后24 h舒芬太尼用量;记录切皮前、切皮后1和5 min时HR和SBP的变化、麻醉后恢复室内和术后24 h VAS疼痛评分,以及患者过敏、局麻药中毒、穿刺损伤等不良反应发生情况。结果两组患者术后24 h内舒芬太尼用量差异无统计学意义[(0.98±0.33)μg/kg vs (0.95±0.28)μg/kg]。患者麻醉后恢复室内和术后24 h VAS疼痛评分差异无统计学意义。椎旁组术中低血压发生率31例(66.0%) vs 11例(22.9%)和去甲肾上腺素用量[(3.5±1.6)μg/kg vs (1.2±0.4)μg/kg]明显高于三点组(P0.01)。两组患者均未见过敏、局麻药中毒、穿刺损伤等不良反应。结论低位前锯肌阻滞、肋缘下腹横肌平面阻滞、腹直肌后鞘阻滞三点阻滞复合可以产生与单侧椎旁阻滞相当的术中和术后镇痛作用,而且前者的低血压发生率明显低于椎旁阻滞,是一种可供临床选择的上腹部神经阻滞方式。     

Complicaciones asociadas a tres técnicas de bloqueo del plexo braquial: revisión sistemática y metaanálisis

BackgroundBrachial plexus block has become one of the most widely-used anaesthetic techniques in the world for upper limb anaesthesia. There are three different brachial blocks techniques: supraclavicular, infraclavicular and axillary block. However, its execution is not exempt from possible clinical complications, and it is not clear which of these is associated with a lower complication rate and greater anaesthetic success.Materials and methodsSystematic review and meta-analysis following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify controlled clinical trials reporting the three techniques. The main outcome was the incidence of anaesthetic complications, and the secondary ones were an anaesthetic success, time of performance and anaesthetic latency.Results25 controlled clinical trials, with 2012 patient, were included. The methodological quality of the included studies is moderate to high. For the main outcome, the main complication reported was a vascular puncture, followed by transient neurological injury, symptomatic diaphragmatic paralysis and pneumothorax. No differences were found in complications associated with the three anaesthetic techniques. Additionally, no differences were found regarding anaesthetic success.ConclusionsAnesthetic complications associated with the three brachial block techniques are low, with no medium and long-term sequelae; however, none of the three techniques seems to be superior among them to reduce these complications. All three techniques are highly successful when performed using ultrasound imaging.     

Axillary block in children: single or multiple injection?

The goal of this double-blind prospective study was to compare the effect of a single injection versus multiple fractionated doses on the onset time and quality of motor and sensory block, obtained in 70 children anaesthetized with axillary block alone. The brachial plexus was identified with a peripheral nerve stimulator, and blocked with 0.5 ml.kg-1 of 1.5% lignocaine with adrenaline. In Group S (single injection), the total volume was injected after location of one nerve. In Group M (multiple fractionated doses), two nerves were located, including necessarily one nerve implicated in the surgical territory. Motor and sensory blocks were assessed according to Lanz's scale before surgery by a blinded observer. A block was considered complete if there was no feeling in at least three nerve territories at 30 min. No difference was found between groups for motor and sensory block quality. However the onset time of the block was faster after multiple fractionated doses (Group M, 25+/-7 min vs Group S, 29+/-4 min) and was faster in younger children (5-9 years: M=23+/-7 min vs S=28+/-5 min, 10-15 years: no difference). There was a significant difference in the quality of the sensory blockade of the musculocutaneous nerve: 18 versus 8 complete blocks, 10 versus 14 incomplete blocks, respectively for Group M versus Group S. No adverse effect was observed and analgesia was prolonged for more than 4 h. We can conclude that, unlike adults, fractionated doses in chilren bring no benefit to the quality of sensory and motor block. Selective block of the musculocutaneous nerve is recommended when a surgical procedure takes place in this territory.     

小剂量骶麻用于肛门直肠手术初探

目的 :探讨小剂量骶麻用于肛门直肠手术的可行性和优越性。方法 :两个阶段肛门直肠手术分别采用常规骶麻方法2 %利多卡因 1 5 2 0mL ,和小剂量骶麻 2 %利多卡因 5 1 0mL。观察麻醉中和术后恢复期并发症。结果 :两组患者均顺利完成手术。小剂量组一过性神经症状 (TNS)发生率为 4 9% ,较常规剂量组 1 6 7%明显降低 (P <0 0 5 )。术后卧床时间小剂量组为 2h ,常规剂量组为 4 6h。尿潴留发生率小剂量组为 7 3% ,常规剂量组为 1 4 4 % (P <0 0 5 )。而术后疼痛无明显差异。结论 :小剂量骶麻用于肛门直肠手术安全、有效 ,简便易行     

超声引导下胸肋间筋膜阻滞的研究进展

肋间神经走行于肋间肌之间,在靠近胸骨的位置发出前皮支分布在皮肤表面,支配前胸壁区域的皮肤感觉。超声引导下胸肋间筋膜阻滞（PIFB）是近年来一种新兴的筋膜平面区域阻滞技术,通过将局麻药注射在胸大肌与肋间肌之间,在肋间神经移行途中将其阻断从而实现前胸壁区域的麻醉与镇痛。PIFB以其有效的镇痛效果、操作安全且易于学习的特点应用于乳腺、胸科、心脏等手术领域中,得到了患者和医师的广泛认可。本文通过对PIFB的解剖情况、操作技术、作用特点及临床应用方面进行论述,为PIFB的更多研究提供参考。     

腰方肌阻滞临床应用的研究进展

腰方肌阻滞是一种将局麻药物注射至腰方肌周围的躯干神经阻滞技术。近年来,腰方肌阻滞的临床应用已成为研究热点,是广受欢迎的镇痛方式。腰方肌阻滞逐渐被应用于剖宫产手术、胃肠道手术、泌尿手术、下肢手术等围术期多模式镇痛,并且在慢性疼痛治疗中也有报道。全文就腰方肌阻滞的应用解剖、穿刺入路、临床应用及可能的作用机制进行综述,为其临床应用提供参考。     

The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks.ResultsAn initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption.ConclusionLocal periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.