PCIA对剖宫产术后病人泌乳及新生儿神经适应能力的影响

剖宫产术后一般采用病人自控硬膜外镇痛(PCEA),但对于硬膜外麻醉失败或禁忌的病人则需采用病人自控静脉镇痛(PCIA).而改用静脉镇痛会增加血药浓度,其是否会影响病人泌乳和新生儿吸允乳汁后的神经适应能力有待探讨.本研究通过与剖宫产术后传统的PCEA比较,拟探讨PCIA对剖宫产术后病人泌乳及新生儿神经适应能的影响.     

术后镇痛对剖宫产术后母乳喂养及新生儿的影响

目的 研究剖宫产术后不同镇痛模式对母乳喂养及新生儿神经和适应能力评分(NACS)的影响.方法 120例单胎足月妊娠拟行剖宫产的产妇,采用持续硬膜外麻醉.依术后镇痛用药不同,随机均分为四组.Ⅰ组:0.2%甲磺酸罗哌卡因;Ⅱ组:吗啡80 μg/h+0.2%甲磺酸罗哌卡因;Ⅲ组:芬太尼3 μg/h+0.2%甲磺酸罗哌卡因;Ⅳ组:术后疼痛时采用盐酸哌替啶肌注作为对照.Ⅰ～Ⅲ组均采用镇痛泵,负荷量为0.2%甲磺酸罗哌卡因5 ml.记录术后2、6、24、48 h的疼痛视觉模拟(VAS)评分.观察恶心、呕吐等不良反应发生情况;随访术后24 h内及术后6w母乳喂养情况;记录术后24 h内新生儿NACS.结果 Ⅰ组术后24、48 h VAS评分高于Ⅱ、Ⅲ组(P＜0.05),Ⅳ组术后各时点VAS评分均高于Ⅱ、Ⅲ组(P＜0.05),且术后2、6 h VAS评分高于Ⅰ组(P＜0.05).术后24 h内及术后6 W母乳喂养情况以及术后24 h内新生儿NACS各组差异无统计学意义.结论 吗啡或芬太尼复合甲磺酸罗哌卡因持续硬膜外镇痛均可有效用于剖宫产产妇术后镇痛,对新生儿和母乳喂养无不良影响.     

剖宫产术后硬膜外丁卡因病人自控镇痛对产妇催乳素的影响

本研究拟观察剖宫产术后产妇催乳素(PRL)水平的变化,以评价丁卡因硬膜外病人自控镇痛(PCEA)对产妇泌乳的作用,为进一步促进母乳喂养提供参考。资料与方法选择健康因头盆不称或臀位而行剖宫产术的足月初产妇50例,年龄23～32岁,体重65～80kg,乳房发育正常、无内分泌疾病,产后出血者、新生儿产伤、体重及出生后Apgar评分异常、非母婴同室、非纯母乳喂养等的产妇排除观察。随机分成2组:PCEA组及对照组,每组25例。     

剖宫产术后硬膜外自控镇痛对产妇泌乳素的影响

有关术后病人硬膜外自控镇痛(PCEA)虽报道较多，但PCEA对剖宫产术后产妇泌乳素(PRL)的影响报道较少。本研究拟探讨PCEA用于剖官产术后的产妇，以评价其对产妇血浆中PRL浓度的影响。     

剖宫产及硬膜外吗啡术后镇痛对产妇泌乳的影响

目的：观察剖宫产及硬膜外吗啡术后镇痛产妇的泌乳状况及血清泌乳素（ＰＲＬ）变化。方法：足月初产妇１２０例均分为四组：Ⅰ组术毕行硬膜外吗啡镇痛;Ⅱ组术毕硬膜外吗啡镇痛,２４小时后追加１次;Ⅲ组未行术后镇痛;阴道自然分娩３０例为Ⅳ组。结果：产后５分钟、２４值变化各组间无显著性差异。Ⅳ组产后２４小时内开发泌乳发生率（４０％）,高于同期所有剖宫产组（２０％）;但４８小时内开始泌乳及７２小时乳汁分泌不足发生率     

剖宫产术后静脉和硬膜外镇痛对泌乳素的影响

产妇产后尽早泌乳是确保婴儿母乳喂养的关键 ,而泌乳和射乳必须在泌乳素及催产素共同作用下完成。影响二者的因素较多 ,如疼痛、焦虑、紧张、交感神经兴奋等均可抑制其分泌[1 ] 。剖宫产术后疼痛势必抑制产妇血浆泌乳素 (ＰＲＬ)的分泌 ,为此 ,本研究拟对比观察剖宫产术后静脉病人自控镇痛 (ＰＣＩＡ)和硬膜外病人自控镇痛 (ＰＣＥＡ)对血浆ＰＲＬ浓度的影响。表 1　ＰＣＡ泵的给药剂量组别负荷量 (ｍｌ)持续速度 (ｍｌ ｈ)ＰＣＡ剂量 (ｍｌ)锁定时间 (ｍｉｎ)每 4ｈ限制量 (ｍｌ)ＰＣＥＡ组ＰＣＩＡ组2～ 3110 5～ 110 5～ 12 015106表 2…     

硬膜外自控镇痛对剖宫产术后的影响探讨

目的本文对孕37-41周选择性剖宫产245例无疾患的孕妇进行自控镇痛对剖宫产术后的影响进行研究。方法所有病例随机分为2组，其中研究组145例，应用硬膜外自控镇痛(PCEA)；对照组100例应用其它止痛方法。观察其镇痛效果、阴道出血及子宫复旧、尿潴留、肛门排气及母乳喂养情况。结果PCEA对剖宫产术的镇痛效果非常显著，术后病人能安静入睡，并能较早下床活动、早开奶，促进乳汁分泌，有益于母乳喂养，而术后肛门排气、子宫复旧及阴道出血情况差异无显著性，尿潴留差异也无显著性。结论PCEA镇痛效果好，改善了产妇剖宫术后生活质量，并能促进母乳喂养，值得临床推广。     

单次剂量吗啡复合罗比卡因用于剖宫产术后PCEA的效果评价

目的 用单次剂量吗啡复合持续剂量不同浓度罗比卡因应用于剖宫产术后硬膜外自控镇痛（patient controlled epidural analgesia,PCEA)，与持续剂量吗啡和罗比卡因相比较，寻求一种减少吗啡用量，更适合下腹部手术的硬膜外自控镇痛方法。方法 80例ASAⅠ-Ⅱ级行子宫下段剖宫产的产妇，随机分为四组，单次剂量吗啡分三组；SMR0.1组，0.1%罗比卡因；SMR0.2组，0.2%罗比卡因，SMR0.05组，0.05%罗比卡因，三组均先单次静注吗啡1mg 氟哌利多持续硬膜外给药，观察产妇24小时内VAS，镇静评分，Prine Henry评分，改良Bromage分级的变化，PONV等不良反应的发生率，记录产妇24小时内用药量。结果 VAS评分；CM组，SMR0.2组大于SMR0.1组，SM0.05组和CM组。SMR0.1组，SMR0.05组尿潴留，排气时间延长发生率明显低于SMR0.2组，CM组，结论 1mg吗啡单次给药复合维持剂量0.1%罗比卡因用于剖宫产术后PCEA能够取得良好的镇痛效果。感觉-运动阻滞分离效果好，不良反应少。     

剖宫产术后不同镇痛方法对产妇泌乳的影响

目的 观察剖宫产术后不同镇痛方法对产妇泌乳的影响.方法 75例剖宫产产妇随机分为硬膜外镇痛组(A组)、静脉镇痛组(B组)和肌注镇痛组(C组),每组25例.观察术后12、24、48 h VAS评分、泌乳情况及血浆泌乳素(PRL)水平.结果 A组和B组镇痛效果明显优于C组(P＜0.05),术后48 h PRL水平也明显高于C组(P＜0.05),且初乳时间明显提前.结论 硬膜外镇痛或静脉镇痛效果优于哌替啶肌注,可提高血浆泌乳素水平,有利于提高母乳喂养成功率.     

硬膜外分娩镇痛对产妇子宫收缩的影响

目的 研究硬膜外分娩镇痛对产妇子宫收缩的影响。方法 随机选择20例有分娩镇痛要求且无产科并发症的单胎初产妇为试验组(E组)，另随机选取拒绝接受分娩镇痛的同类产妇20例为对照组(C组)。在 E 组产妇宫口开3.0cm 时行 L_(2～3)间隙硬膜外穿刺，接电脑镇痛泵行病人自控镇痛。分别测定产妇宫口开3cm(T_1)、宫口开3cm 后1h(T_2)和宫口开全时(T_3)血浆前列腺素 E_2(PGE_2)、催产素和皮质醇浓度，以及胎儿娩出时脐静脉血浆和羊水中皮质醇、催产素和 PGE_2浓度。同时记录产妇宫缩情况、产程经过、分娩方式及新生儿 Apgar 评分。结果 与 T_1时相比，两组 T_2、T_3时血浆 PGE_2升高(P<0.05或O.01)，T_3时 C 组皮质醇浓度升高(P<0.05)；与 C 组相比，E 组产妇 T_2、T_3时血浆皮质醇浓度降低(P<0.05或0.01)，T_2时宫腔压力和宫缩持续时间降低(P<0.05或0.01)，_2时宫缩间隔时间较 C 组延长(P<0.01)。脐血和羊水各指标及 VAS 评分组间比较差异无显著性(P>0.05)。结论 硬膜外分娩镇痛可引起子宫收缩力的—过性下降，但其与子宫收缩激素无关，对分娩过程也没有不良影响。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.