Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis

Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side-effects. We undertook a systematic review, meta-analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty-nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high-quality evidence), without sub-group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high-quality evidence). However, a sub-group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub-group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high-quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.     

Hematoma subdural intracraneal tras punción dural accidental: caso clínico

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.     

痹祺胶囊治疗类风湿性关节炎的药效研究及网络机制预测

目的 基于Ⅱ型胶原诱导的类风湿性关节炎（rheumatoid arthritis,RA）大鼠模型和网络药理学方法探讨痹祺胶囊的药效作用及作用机制。方法 SD大鼠采用Ⅱ型胶原蛋白造模,造模成功大鼠随机分为模型组,痹祺胶囊（0.05、0.10、0.20、0.40 g/kg）组及泼尼松（10 mg/kg）组和雷公藤总苷（10 mg/kg）组,连续给药15 d。持续监测大鼠体质量、足趾肿胀度和关节炎评分,苏木素-伊红染色考察大鼠踝关节病理变化,ELISA法测定血清细胞因子含量,初步评价痹祺胶囊治疗效果。选择痹祺胶囊中39个化合物为研究对象,依据反向药效团匹配方法和TCMSP、Uniprot等数据库预测化合物作用靶点,与通过OMIM、Dis Ge Net等数据库收集的RA相关靶点相互交互,将交互靶点借助Omicsbean、STRING等数据库平台对获得靶点进行基因本体功能和京都基因与基因组百科全书（Kyoto encyclopedia of genes and genomes,KEGG）通路富集分析,利用Cytoscape软件构建“药材-化合物-靶点-通路-功效-疾病”网络,预测其可能的作用机制...     

腹腔镜辅助腹横肌平面阻滞技术临床应用进展

腹横肌平面（TAP）阻滞技术在腹部手术中的应用经历了一个复杂的阶梯式的发展过程,由外科医生主导的腹腔镜辅助腹横肌平面阻滞（Lap-TAP）是近年来国际上一种新兴的围手术期镇痛方式,逐渐被临床推广应用。与超声引导下TAP阻滞技术相比,Lap-TAP可在腹腔镜直视侧腹壁下,由外科医师独立完成操作,无需麻醉科医师及超声设备,具有良好的围手术期镇痛效果,是一种更为安全、有效、简单、省时的镇痛方式,可推荐其作为超声引导下TAP阻滞的替代方法,广泛应用于各腹部微创外科领域的围手术期镇痛。     

近端联合远端收肌管阻滞在全膝关节置换术患者术后镇痛和早期功能康复中的应用

目的 探讨近端联合远端收肌管阻滞在全膝关节置换术患者术后镇痛和早期功能康复中的应用。方法 选取2019年1月至2020年12月在解放军总医院第六医学中心择期行单侧全膝关节置换术患者90例,按随机数字表法分为3组,每组30例。A组为对照组,于超声引导下行股神经联合腘窝上坐骨神经阻滞;B组为近端联合远端收肌管阻滞组,于超声引导下分别行收肌管近端和远端阻滞;C组为右美托咪定联合收肌管阻滞组,于超声引导下将罗哌卡因与右美托咪定混合液分别注射至收肌管近端和远端。比较3组患者术后6 h(T₁)、12 h(T₂)、24 h(T₃)和48 h(T₄)时静息VAS评分,术后T₃和T₄时运动VAS评分,48 h内羟考酮和氟比洛芬酯使用情况;以及术后24 h(T₃)、48 h(T₄)和72 h(T₅)膝关节活动范围(ROM)和股四头肌肌力;记录3组患者术后首次直腿抬高≥10 cm时间,术后首次下床活动时间,术后7...     

Aortocaval compression in the sitting and lateral decubitus positions during extradural catheter placement in the parturient

We prospectively studied the incidence of concealed aortocaval compression in parturients at term during identification of the extradural space. Forty ASA I or II parturients, at term and in active labour, who requested extradural analgesia were randomly allocated to one of two groups. Parturients in the first group (n = 22) were positioned in the left lateral decubitus position and those in the second group (n = 18) were in the sitting position. Cardiac output (CO) was recorded at one-minute intervals for five minutes before extradural catheter placement (supine position with a 15° wedge under the right side), and during and thereafter for five minutes (in the supine wedged position), using the BoMED NCCOM3-R7 thoracic electrical bioimpedance (TEB) monitor. The average of five CO_TEB recordings before positioning the patient were compared with the average of five CO_TEB measurements during and after extradural space identification. A change of >25% CO_TEB was considered beyond machine variability. Upper limb arterial pressure was recorded at one-minute intervals. In the left lateral decubitus position, 17 of 22 patients demonstrated a >25% reduction in CO_TEB compared with five of 18 patients in the sitting position (X²,P <0.01). The percentage change in CO_TEB in the lateral decubitus position (?29.8%, 95% CI ?17% to ?44%) was greater than the sitting position (?9.8%, 95% CI +36% to ?32%) (P <0.01). A decreased incidence of aortocaval compression during identification of the extradural space was demonstrated in the sitting position when compared with the left lateral decubitus position.     

Calcium channel modulation by dihydropyridines modifies sufentanil-induced antinociception in acute and tolerant conditions

Summary The study was aimed at elucidating the possible participation of l-type Ca²⁺ channel in the acute analgesic effect of an opiate and the development of tolerance to this action. Sufentanil, a selective p agonist, and two dihydropyridines, the Ca²⁺ antagonist nimodipine and the Ca²⁺ agonist Bay K 8644, were selected. The tail-flick test was used to assess the nociceptive threshold. In naive rats, nimodipine (200 g/kg) potentiated the analgesic effect of sufentanil reducing the ED₅₀ from 0.26 to 0.08 g/kg. Similar results were observed with its (–)-enantiomer Bay N 5248, while the (+) enantiomer Bay N 5247 was ineffective. Tolerance to the opiate was induced by chronic subcutaneous administration of sufentanil with minipumps (2 g/h, 7 days). In these conditions the dose-response curve to sufentanil was displaced to the right and the ED₅₀ was increased to 1.49 g/kg. In tolerant rats, nimodipine preserved its potentiating ability and prevented the displacement to the right of the sufentanil dose response-curve (ED₅₀ = 0.48 g/kg). When nimodipine was pumped (1 g/h, 7 days) concurrently with sufentanil, the development of tolerance to the opioid was not disturbed. However, the expression of tolerance was abolished and even the effect of acutely administered sufentanil was markedly potentiated (ED₅₀ = 0.03 g/kg). Similar experiments were performed with Bay K 8644. In naive rats, Bay K 8644 at a low dose (20 g/kg) that behaves as a calcium agonist, antagonized the analgesic effect of sufentanil (ED₅₀ = 0.58 g/kg), whereas at a high dose (200 g/kg) it potentiated this action (ED₅₀ = 0.15 g/kg). In tolerant rats, Bay K 8644 (20 g/kg) preserved its antagonizing ability inducing a displacement to the right of the sufentanildose-response curve (ED₅₀ = 4.2 g/kg). When Bay K 8644 was pumped (1 g/h, 7 days) concurrently with sufentanil, it enhanced the expression of tolerance to the opiate (ED₅₀ = 3.8 g/kg). These results suggest that the calcium fluxes through the l-type channel in neurones are functionally linked to the activation of the opiate receptor: the blockade of the channel increased the potency of sufentanil, whereas its activation reduced the potency of the opiate. In chronic experiments, DHPs concurrently administered with sufentanil did not affect the development of tolerance to the opiate. However, nimodipine prevented the expression of this phenomenon. Even more, the animals became hypersensitive to the opiate suggesting that the adaptative mechanisms induced by chronic opiate could be affected by chronic nimodipine.This work was supported by grants from Universidad de Cantabria-Caja Cantabria (1988) and Bayer AG, Wuppertal, FRGPredoctoral Fellow: Fondo de Investigaciones Sanitarias de la Seguridad Social.Send offprint requests to: M. A. Hurlé at the above address     

梅笠草提取物的抗炎及镇痛作用

[目的 ]探讨梅笠草提取物的抗炎及镇痛作用 .[方法 ]采用巴豆油所致小鼠耳壳肿胀的方法 ,测定耳片的肿胀度 ;用冰醋酸所致小鼠的扭体次数 ,测定小鼠的扭体反应次数 .[结果 ]梅笠草对巴豆油所致小鼠耳壳肿胀有抑制作用 ,与对照组相比有显著性差异 ;同时能减少冰醋酸所致小鼠的扭体次数 ,与对照组相比有显著性差异 .[结论 ]梅笠草提取物具有一定的抗急性炎症和抗镇痛作用     

曲马多骶管注入用于小儿术后镇痛的初步研究

目的观察骶管注入1mg/kg曲马多用于小儿术后镇痛的效果和安全性.方法∞例在骶麻下行斜疝修补术小儿随机分为3组A组骶管注入1%利多卡因,B组注入1%利多卡因+0.15%布比卡因,C组注入1%利多卡因+1mg/kg曲马多,注药容积为1ml/kg.术后4、8、12、24h随访并记录疼痛评分(LPS)及副作用.结果LPS＜3级者B组、C组各时间点明显多于A组,平均镇痛时间C组明显长于A、B组(P＜0.01),清醒后再嗜睡时间、术后恶心呕吐发生率3组间无明显差异,C组肌力恢复时间、肛门排气时间明显短于B组(P＜0.01).结论曲马多1mg/kg骶管注入是小儿斜疝修补术较好的术后镇痛方法之一.     

大鼠中枢内源性镇痛系统内GABAB受体的分布

目的：观察α－氨基丁酸B受体（GABAR）在大鼠中枢内源性镇痛系统内的定位分布,方法：GABABR特异性抗体的免疫组织化学染色方法：结果：GABABR样阳性胞体较密集地分布于中缝核簇的核团,如中缝背核,中缝正中核,中缝桥核,中缝大核,中缝苍白核,中缝隐核,此外,中脑导水管周围灰质和巨细胞网状核α部内也有GABAR样阳性胞体,上述核团内亦可见GABABR样阳性纤维和终末,结论：中枢内源性镇痛系统内有GABABR样阳性胞体,纤维及终末,这些阳性结构可能与对该系统的调控有关。