联合椎管内麻醉时硬膜外注药升高阻滞平面的机制研究

探讨联合椎管内麻醉时硬膜外注药升高阻滞平面的机制。方法：３０例下肢矫形手术患者均采用蛛网膜下隙与硬膜外联合穿刺针行Ｌ２－３穿刺,蛛网膜下隙注入等比重的０．７５％布比卡因１．５ｍｌ后硬膜外置管。患者随机分成三组,每组１０例：硬膜外不给药（Ａ组）,蛛网膜下腔注射药后１５、２０、２５分钟经硬膜外导管给予２％利多卡因各３ｍｌ（Ｂ组）或生理盐水各３ｍｌ（Ｃ组）。结果     

Regional versus general anesthesia in high-risk surgical patients: The need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

Finland's first anaesthesia revealed by newspapers

Background: According to the literature on the history of anaesthesia, Finland's first anaesthesia was given on March 8, 1847 for a ligature of an aneurysm of the subclavian artery. It has, however, not been possible to verify the date with certainty. We therefore wanted to find out whether newspapers might give additional information and how this exceptionally important medical invention had been received by the Finnish newspapers.
Methods: Microfilms of the 10 newspapers which appeared in Finland in 1847 were studied at the Helsinki University library.
Results: The first report which made reference to English newspapers was published on February 10 by "Borgå Tidning". On March 6, "Helsingfors Tidningar" wrote that two anaesthesias had already been given in Helsinki; the first of them for a difficult varicose veins operation and the second for an exarticulation of a shoulder. But there was no information regarding the dates of the operations. Fortunately, both operations had been recorded in the patient diary of the clinic, although without any information about the anaesthesia. According to the diary, Johan August Örn was operated for varicose veins on February 16 and Anders Gustaf Henrikson had his right arm exarticulated on March 3. Both patients recovered. In total, only six pieces of news on anaesthesia were found.
Conclusions: Finland's first anaesthesia was given on February 16, 1847, which is three weeks earlier than had been previously assumed.     

不同麻醉方式对血液流变学的影响

麻醉对外科手术患者术中及术后早期血液流变学产生一定的影响,这可能与围手术期血栓形成等因素有一定的关联.而不同麻醉方式对血液流变学的影响不同,现就此进行综述,为临床麻醉方式的选择提供一定的参考.     

Screen height as an ergonomic factor in laparoscopic surgery

Background: The increasing number of routinely performed laparoscopic operations causes the surgeons’ “screen work” time to rise constantly. A new ergonomic workload on the surgeons’ upper spine and shoulders is created as a result of the standard screen height position on top of the laparoscopy towers. Methods: Eight surgeons in the authors’ surgical department were evaluated for the inclination/reclination angle of their cervical spine when using the laparoscopy towers in the authors’ department and also at their favorable screen height. Results: The laparoscopy towers used in the authors’ department made 3° to 14° reclination of the cervical spine necessary. The interviewed surgeons preferred a position of slight inclination, with a median of 160 cm measured from the central screen height to the floor. Conclusion: Monitors of laparoscopy towers should be adapted to the surgeon’s preferred screen height: at eye level frontally with a neutral or slight inclination of the cervical spine. The authors suggest a central screen height of 160 cm, with the monitor positioned in front of the surgeon. Newer equipment from the industry should be provided.     

Musculoskeletal Sonopathology and Ultrasound-Guided Regional Anesthesia

The use of real-time ultrasound guidance has revolutionized the practice of regional anesthesia. Ultrasound is rapidly becoming the technique of choice for nerve blockade due to increased success rates, faster onset, and potentially improved safety. In the course of ultrasound-guided regional anesthesia, unexpected pathology may be encountered. Such anomalous or pathological findings may alter the choice of nerve block and occasionally affect surgical management. This case series presents a variety of musculoskeletal conditions that may be encountered during ultrasound-guided regional anesthesia practice.     

Comparison of Acceptance,Preference, and Efficacy Between Jet Injection INJEX and Local Infiltration Anesthesia in 6 to 11 Year Old Dental Patients

Needleless devices have been developed to provide anesthesia without injections. Little controlled research has examined the acceptability of needleless devices in pediatric patients. The aims of the study were to compare children’s acceptance and preference for one type of needleless jet injection with classical local infiltration as well as to evaluate the efficacy of the needleless anesthesia. Eighty-seven nonfearful children with no previous experience of dental anesthesia were studied using a split-mouth design. The first dental procedure was performed with the classical infiltration anesthesia. The same amount of anesthetic was administered using the INJEX needleless device in a second session 1 week later, during which a second dental procedure was performed. Patients rated their acceptance and preference for the 2 methods, and the dentist recorded data about the need for additional anesthesia. More negative experiences were reported for the INJEX method. Most (73.6%) of the children preferred the traditional method. Among the 87 treatment procedures attempted following the use of INJEX, 80.5% required additional anesthesia, compared with 2.3% of those attempted following traditional infiltration. Traditional infiltration was more effective, acceptable, and preferred, compared with the needleless INJEX.     

Comparação entre anestesia intravenosa e inalatória na náusea e vômito pós‐operatórios em laparotomia: estudo clínico randomizado

BackgroundPostoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients’ characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV.MethodsA single‐blinded prospective randomized clinical trial on 105 patients aged 18 − 65 years was carried out. Patients were divided in two groups of Total Intravenous Anesthesia (TIVA) and Inhalational anesthesia. The incidence and severity of PONV were examined at 0, 2, 6, 12, and 24 hours after the surgery. The use of a rescue antiemetic was also evaluated.ResultsFifty point nine percent of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p < 0.001). The incidence of vomiting was reported in 11.3% of the Inhalational group and 3.8% of the TIVA group (p = 0.15), and 24.5% of patients in the Inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p = 0.043).ConclusionThe incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug, and the severity of nausea in patients were significantly lower in the TIVA group.     

Semi-automated,slow subcutaneous infusion anesthesia (SIA) with diluted mixtures of prilocaine and ropivacaine

In recent years it has been found that local anesthesia, which often suffices for surgery of the skin and superficial structures, can be adequately administered using large amounts of highly diluted anesthetic solutions combined with epinephrine. This has considerably increased application of local anesthesia in plastic surgery. Using one or more conventional infusion pumps for slow subcutaneous infusion anesthesia (SIA), we injected mixed anesthetic solutions painlessly and automatically into the subcutaneous layer. The local anesthetics used were equivalent mixtures of prilocaine and ropivacaine (Xylonest and Naropin); these were diluted with original Ringers solution containing epinephrine (1:1,000,000) in 500-ml bottles. The concentrations of the mixtures varied between 0.3% and 0.06% depending on the requirements of surgery. Routinely available 18- to 30-gauge needles were used. The speed of injection varied between 30 ml and 1500 ml per hour depending on the location, the requirements of surgery, and the needle size. Volumes usually ranged from 2 ml to 1000 ml depending on the concentrations. The maximum dose was approximately 4 mg of prilocaine and 2 mg/kg of ropivacaine, which is the maximum tolerated dose. Regardless of secondary disorders, all patients scheduled for skin and lymph node operations under local anesthesia underwent surgery using this kind of anesthesia, including those for the nose and ear region. No suprarenin was added for nerve blocks of the fingers and penis. This technique was used in 20,310 major and minor skin operations in 11,810 patients ranging in age from 0.5 years (510 children under 14 years) to 95 years (mean age 55 years; 49% females, 51% males), including all types of local flaps and grafts. There were no complications whatsoever from local anesthesia. The technique proved safe and comfortable even for children and very sensitive patients. The median duration of postoperative anesthesia was 4.3 h (maximum 23 h). We found that experience is required for correct selection of the needle position, the flow rate, and the volume.     

Regional versus general anesthesia in high-risk surgical patients: the need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

Lumbar epidural block reduces cough strength in healthy young subjects

Effects of lumbar epidural block on maximum expiratory strength were studied in 12 healthy volunteers. Subjects performed maximum expiratory effort against occluded airway at functional residual capacity (FRC) and total lung capacity (TLC) while measuring airway pressure and electromyogram of the abdominal muscles (EMGab). Cough strength was assessed by maximum expiratory pressure (PE_max) and peak EMGab (peak-EMGab). Following injection of 2% lidocaine 17.8±1.1 ml into the lumbar epidural space (L2.3±0.4), upper levels of analgesia ranged from T11 to T4 (T7.8±1.3). Peak-EMGab and PE_max were significantly reduced by lumbar epidural block at both lung volumes. Compared with severe reduction in peak-EMGab, PE_max was well maintained at TLC, but changes in PE_max were identical to those in peak-EMGab at FRC. When analgesia spread to higher than T6, PE_max at TLC decreased considerably. We conclude that lumbar epidural block producing analgesia above T6 paralyzes the abdominal muscles and severely impairs the ability of effective cough in healthy young men.     

胆道手术全麻-硬膜外复合麻醉围拔管期心血管反应的临床观察

目的 探讨全麻-硬膜外复合麻醉对胆道手术病人围拔管期心血管反应的影响。方法 ASAⅠ-Ⅱ级择期胆道手术患者40例,随机分成两组：Ⅰ组20例,采用单纯全麻;Ⅱ组采用全麻复合硬膜外麻。观察并记录两组术前、拔管前5 m in、拔管、拔管后5 m in的SBP、DBP、HR。结果Ⅰ组在围拔管期各时点、Ⅱ组在拔管时SBP、DBP、HR较术前显著升高（P〈0.01）;组间比较,Ⅱ组围拔管期各时点SBP、DBP、HR均低于与Ⅰ组（P〈0.01）,全麻用药量也少于Ⅰ组（P〈0.05）。结论 全麻-硬膜外复合麻醉有利于维持胆道手术病人围拔管期血流动力学的相对稳定。