右美托咪定对老年性全髋关节置换术患者小剂量布比卡因腰麻的影响

目的将右美托咪定(DEX)应用于小剂量布比卡因腰麻的老年性全髋关节置换术中,探讨其影响及可行性。方法 60例实施全髋关节置换术的老年患者,ASAⅡ~Ⅲ级,采用随机数字表法分为对照组(C组,n=30)和DEX组(D组,n=30),两组分别采用布比卡因6 mg或布比卡因6 mg与DEX 3μg混合液进行腰麻。结果 D组术中的心率较术前下降明显(P<0.05);术中两组出现心动过缓概率无统计学差异(P>0.05);手术医师满意度D组显著高于C组(P<0.05),术后寒战C组较D组明显(P<0.05);感觉及运动阻滞方面,D组优于C组(P<0.05);镇静评分上,D组较C组效果好,两者有统计学差异(P<0.01);比较两组术后镇痛药的应用,无论是对乙酰氨基酚,还是双氯芬酸、曲马朵,D组应用的人数都明显少于C组(P<0.01)。结论 DEX应用于小剂量布比卡因腰麻的老年患者全髋置换术中,可以延长麻醉时间,具有一定镇痛效应,不良反应少,术者满意度更高。     

The effect of bupivacaine with fentanyl temperature on initiation and maintenance of labor epidural analgesia: a randomized controlled study

BackgroundLabor epidural analgesia is highly effective, but can be limited by slow onset and incomplete blockade. The administration of warmed, compared to room temperature, bupivacaine has resulted in more rapid onset epidural anesthesia. We hypothesized that the administration of bupivacaine with fentanyl at 37°C versus 20°C would result in improved initial and ongoing labor epidural analgesia.MethodsIn this prospective, randomized, doubled blinded study, 54 nulliparous, laboring women were randomized to receive epidural bupivacaine 0.125% with fentanyl 2 μg/mL (20 mL initial and 6 mL hourly boluses) at either 37°C or 20°C. Pain verbal rating scores (VRS), sensory level, oral temperature, and side effects were assessed after epidural loading (time 0), at 5, 10, 15, 20, 30, 60 min, and at hourly intervals. The primary outcome was the time to achieve initial satisfactory analgesia (VRS ⩽3). Secondary outcomes included ongoing quality of sensory blockade, body temperature and shivering.ResultsThere were no differences between groups in patient demographics, initial pain scores, cervical dilatation, body temperature or mode of delivery. Epidural bupivacaine at 37°C resulted in shorter mean (±SD) analgesic onset time (9.2 ± 4.7 vs. 16.0 ± 10.5 min, P = 0.005) and improved analgesia for the first 15 min after initial bolus (P = 0.001–0.03). Although patient temperature increased during the study (P < 0.01), there were no differences between the groups (P = 0.09). Six (24%) and 10 (40%) patients experienced shivering in the 37°C and 20°C groups, respectively (P = 0.23).ConclusionsThe administration of epidural 0.125% bupivacaine with fentanyl 2 μg/mL at 37°C versus 20°C resulted in more rapid onset and improved labor analgesia for the first 15 min. There was no evidence of improved ongoing labor analgesia or differences in side effects between groups.     

Systemic toxic effects of local anaesthetics

Local anaesthetics are widely used in the provision of local/regional anaesthesia and the management of acute and chronic pain. Their mechanism of action temporarily inhibits voltage gated sodium channels in neuronal plasma membranes. Local anaesthetic systemic toxicity (LAST) is a serious yet largely preventable complication that can occur by any of the multiple routes of administration. LAST predominantly affects the central nervous and cardiovascular systems. Awareness of LAST and vigilance during administration of local anaesthetics may help in early recognition and successful management of the toxicity. Intralipid emulsion (ILE) infusions have been successfully used in reversing local anaesthetic-induced cardiotoxicity. Since 2007 in the UK, ILE infusion has been incorporated into the safety guidelines for management of LAST.     

硬膜外自控镇痛治疗晚期癌痛的疗效观察

目的 评价硬膜外自控镇痛(PECA)对晚期癌痛的临床疗效,特别是剧烈的顽固性疼痛.方法 观察了14 例疼痛较剧烈的患者,其虽经不同途径(口服、皮下及静脉) 使用大剂量阿片类药物,但未能很好地控制疼痛,同时毒副作用较大.对此采用PECA 方法用于以上患者的镇痛,在减少阿片类药物用量的同时使镇痛效果明显提高.注射液浓度依病变部位及疼痛程度而定.一般为0. 75 %布比卡因40 ml药液中加入吗啡10 mg～20 mg、氟哌啶5～10 mg.同时,应严格锁定每次注液量及间隔时间.治疗效果由患者采用0～10 疼痛自测分级表自行划定.结果 癌痛完全缓解11例(78.57%),部分缓解3 例(21.43 %),缓解率为(100.0%) .治疗前后疼痛程度差异有显著性(P＜0.01),患者治疗后生活质量较治疗前明显改善(P＜0.05),毒副作用明显减轻.结论 PECA 治疗晚期顽固性癌痛疗效确切,方便、安全,且能增强镇静和抗焦虑作用,改善癌症患者的生活质量.     

Continuous paravertebral block for pain relief in unilateral multiple rib fracture: A case series

Rib fracture secondary to blunt chest trauma is an indicator of the severity of injury. It is one of the factors associated with morbidity and mortality in blunt chest trauma. Current management of such patients stresses on provision of adequate analgesia and early institution of aggressive physiotherapy. The current study evaluates the analgesic efficacy of continuous thoracic paravertebral infusion of Bupivacaine in unilateral multiple rib fracture (MRF).

Study design

Retrospective, non-randomized case series of 11 patients with unilateral MRF.

Method

Thoracic paravertebral (TPV) space on the side of fractured ribs was catheterized with an epidural catheter. TPV block was initiated with 0.3 ml/kg body weight of 0.25% Bupivacaine with adrenaline. The block was maintained with a continuous infusion of 0.2% Bupivacaine 30 min later, at 0.1–0.2 ml/(kg/h) for a total of 4 days or for the length of admission, which ever was earlier.

Patients were monitored for pain scores at rest and when asked to cough and vital capacity manoeuvre, respiratory rate, oxygen saturation, oxygen index (PaO₂/FiO₂) and percentage change in incentive spirometry.

There were significant improvements in pain scores at rest (p = 0.0097), on cough (p = 0.0039) and vital capacity manoeuvre (p = 0.0078). Other respiratory parameters like respiratory rate, PaO₂ and oxygen index showed persistent improvement from baseline. None of the patients had any complications or side effect related to procedure and technique.

Conclusion

Our study confirms that continuous TPV block is a safe and effective technique for analgesia in patients with unilateral MRF.     

腹腔内局麻药和丁丙诺啡对腹腔镜术后镇痛效果观察

目的 :评价腹腔内给予局麻药物和丁丙诺啡对腹腔镜胆囊切除术后镇痛效果。方法 :腹腔镜胆囊手术结束 ,90例病人被随机分配到 3组 ,每组 30例病人 ,组 1在腹腔内注射 0 .2 5 %布比卡因 30ml,组 2在腹腔内注射 0 .2 5 %布比卡因 30ml+丁丙诺啡 0 .15mg ,组 3注射 0 .2 5 %布比卡因 30ml+丁丙诺啡 0 .3mg。分别在术后的 1、2、6、12h记录病人在安静和咳嗽状态下的模拟镇痛评分 ,记录术后镇痛时间和各种不良反应。结果 :术后 6和 12h ,在安静和咳嗽状态下 ,组 3对切口和腹腔内疼痛的镇痛效果均较其余两个组好 (P <0 .0 5 ) ,组 3的肩膀疼痛的发生率较其余两个组明显降低 (P <0 .0 5 ) ,术后镇痛时间 3组依次分别是 4 .6± 2 .3h ,15 .3± 5 .4h和 2 3.6± 5 .6h ,组 3较其他两组明显延长 (P <0 .0 5 ) ,组 2较组 1亦明显延长 (P <0 .0 5 )。术后恶心、呕吐的发生率在组 2和组 3之间没有差异 ,但较组 1明显增加 (P <0 .0 5 ) ,其余并发症无明显差异。结论 :在腹腔镜胆囊切除术后的病人 ,腹腔内给与局麻药和丁丙诺啡的术后镇痛效果较单纯使用腹腔内局麻药效果更加明显 ,同时可以明显减少术后肩膀疼痛的发生 ,但应注意恶心、呕吐的发生。     

Irrigation with bupivacaine at the surgical bed for postoperative pain relief after laparoscopic cholecystectomy

Purpose:

The aim of this study was to evaluate the effect of bupivacaine irrigated at the surgical bed on postoperative pain relief in laparoscopic cholecystectomy patients.

Methods:

This study included 60 patients undergoing elective laparoscopic cholecystectomy who were prospectively randomized into 2 groups. The placebo group (n=30) received 20cc saline without bupivacaine, installed into the gallbladder bed. The bupivacaine group (n=30) received 20cc of 0.5% bupivacaine in at the same surgical site. Pain was assessed at 0, 6, 12, and 24 hours by using a visual analog scale (VAS).

Results:

A significant difference (P=.018) was observed in pain levels between both groups at 6 hours postoperatively. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance.

Conclusions:

In our study, the use of bupivacaine irrigated over the surgical bed was an effective method for reducing pain during the first postoperative hours after laparoscopic cholecystectomy.     

Safety and efficacy of extended-release bupivacaine local anaesthetic in open hernia repair: a randomized controlled trial

Background: Pain relief remains a major problem in hernia surgery. SABER‐Bupivacaine is an investigational extended‐release formulation of bupivacaine in a resorbable matrix, which may provide up to 72 h of local pain relief. Methods: A double‐blinded, randomized controlled trial was undertaken to evaluate the safety and efficacy of SABER‐Bupivacaine. Consented patients (n= 124) undergoing open inguinal hernia repair at five sites in Australia and New Zealand were randomized to receive either 2.5 (330 mg) or 5.0 mL (660 mg) of SABER‐Bupivacaine or SABER‐Placebo administered to the surgical wound at the end of the procedure. Analgesic efficacy and safety was evaluated. Results: SABER‐Bupivacaine appeared safe with no difference in the incidence of side effects compared with SABER‐Placebo. The 5.0 mL dose of SABER‐Bupivacaine reduced the mean area under the curve of pain intensity on movement compared with SABER‐Placebo (2.47 versus 3.60; P= 0.0033) and decreased the number of patients requiring supplemental opioids by 26% (although not statistically significant; P= 0.0909). Normal wound healing was reported throughout the trial and at 3‐ and 6‐month follow‐up in every treatment group. Conclusion: After open inguinal hernia repair, SABER‐Bupivacaine administered at the surgical site was safe and provided pain relief, reduced the need for supplemental (oral and parenteral) analgesia and did not impair wound healing.     

电针“委中”穴对大鼠腰多裂肌损伤后的再生促进作用及对IGF-1表达的影响

目的观察电针委中穴对腰部多裂肌损伤后的干预作用及对胰岛素样生长因子1(insulin like growth factor 1,IGF-1)表达的影响,探求委中穴对大鼠腰肌损伤后再生修复的可能机制。方法雄性SD大鼠120只,随机分为空白组、模型对照组、模型组、电针委中组、电针肾俞组,共5组,观察3个时间点(4天、7天、14天)的变化,每个时间点8个样本。将0.5%布比卡因盐酸盐溶液按每点100μL注射于模型组和电针组大鼠L4、L5水平的多裂肌上。模型对照组采用同样方法注射生理盐水,空白组不做处理。造模后进行电针双侧委中穴或肾俞穴分别治疗4天、7天、14天,HE染色观察肌细胞形态学的改变,免疫组化方法检测肌细胞IGF-1的表达。结果造模前后多裂肌形态学改变显著,损伤后第14天仍未完全恢复。电针委中组与电针肾俞组从形态学上优于模型组。第4、7天模型组多裂肌IGF-1的表达显著高于空白组(P0.01);第4天电针委中组表达显著高于模型组(P0.01),电针委中组表达高于电针肾俞组(P0.05),电针肾俞组表达高于模型组(P0.05),而在第14天,电针肾俞组表达显著高于模型组与电针委中组(P0.01)。结论电针委中穴和电针肾俞穴均能够促进大鼠腰多裂肌损伤后的再生,电针委中穴在肌肉损伤的早期效果显著。