Factors Influencing the Respiratory Capacity after Upper Abdominal Surgery

The analgesic requirement and some factors influencing the respiratory capacity after upper abdominal surgery were studied during the first 2 days postoperatively in 417 patients, aged 17 to 84 years, undergoing surgery in the upper part of the abdomen. The operations were cholecystectomy or choledocholithotomy through a subcostal incision, partial gastric resection, repair of a diaphragmatic hernia or vagotomy through a midline incision. Pain relief was achieved in a random order either by intercostal block (i.c.b.) and centrally acting analgesics on demand, or by centrally acting analgesics alone. The analgesic demand was recorded, and the respiratory capacity was monitored by the peak expiratory flow rate (PEF). A smaller analgesic requirement and a smaller change in PEF were found after cholecystectomy than after any other kind of surgery. The demand for analgesics was age-dependent, and patients under 60 years of age demanded more than those aged 60 years and older. Bilateral i.c.b. given after surgery through a midline incision had few advantages, but unilateral i.c.b. following cholecystectomy and choledocholithotomy with a subcostal incision had positive effects. Thus it decreased the demand for centrally acting analgesics and resulted in higher PEF values than without i.c.b. for cholecystectomy during the period of effective nerve block and for choledocholithotomy for 2 whole days postoperatively. Smokers seemed to benefit from i.c.b. for 2 postoperative days. The reduction of PEF after cholecystectomy also seemed to be related to the duration of treatment with centrally acting analgesics.     

Comparison of Intramuscular Analgesia, Intercostal Block, Epidural Morphine and On-Demand-i.v.-Fentanyl in the Control of Pain after Upper Abdominal Surgery

Eighty patients undergoing upper abdominal surgery were randomly allocated to four groups according to the postoperative pain treatment. All patients had a standardized balanced anaesthesia and for postoperative analgesia either intramuscular oxycodone and/or metamizol (IM), intercostal block with 0.5% bupivacaine (IC), epidurally 4 mg morphine (EM) or i.v. infusion of fentanyl 0.54-0.99 micrograms min-1 + on-demand boluses of 7.2-13.5 micrograms (ODAC) were given. The pain intensity 2 h postoperatively was similar in all groups, mean score ranging from 3.2-4.3 on a scale from 0-10. At 24 h also, when additional intramuscular analgesics had been administered if needed, the mean pain scores did not vary much; 2.4 in the ODAC group to 3.4 in the IC group. The time until the first request for additional analgesia was longer in the EM group than in the IM group (7.5 h vs. 3.5 h). There were no differences between the groups in chest X-ray, peak expiratory flow or respiratory rate postoperatively, but in the capillary blood-gas analyses there was a greater number of slightly elevated PCO2 values (6.0-7.3 kPa) in the ODAC group than in the others. The amount of fentanyl infused in 24 h to the ODAC patients varied considerably, 814-2233 micrograms, as did the number of on-demand boluses, 3-155. At 24 h, an efficacy rating "good" was distributed as follows: IM 9/20, IC 11/20, EM 11/20 and ODAC 13/20. In the whole patient material 92.5% rated their condition as "good" or "fair".     

第3肋间小切口行心脏多瓣膜病变手术与胸骨正中切口手术的比较

目的探讨第3肋间小切口行心脏多瓣膜病变的手术方法及效果。方法 2013年4月~2014年4月,采用第3肋间小切口行心脏多瓣膜成形或置换手术23例,与同期23例另一组医师的胸骨正中切口多瓣膜手术进行比较,观察指标包括手术时间、体外循环时间、主动脉阻断时间、ICU停留时间、术后住院时间、输血率及输血量、术后疼痛指数及满意度评分等。结果小切口组在术后住ICU时间、术后住院时间、术后总胸引量、术后1个月疼痛评分及患者满意度评分方面明显好于正中切口组[(40.4±7.1)h vs.(48.8±8.3)h,t=-3.713,P=0.001;中位数6 d(5~7 d)vs.9 d(8~14 d),Z=-5.927,P=0.000;(479.6±81.2)ml vs.(855.7±114.7)ml,t=-12.820,P=0.000;(5.1±0.9)分vs.(6.2±0.7)分,t=-4.828,P=0.000;(9.2±0.4)分vs.(7.1±0.8)分,t=10.908,P=0.000],但手术时间、体外循环时间、主动脉阻断时间长[(4.64±0.47)h vs.(4.15±0.45)h,t=3.626,P=0.001;129 min(113~153 min)vs.101 min(85~133 min),Z=-4.572,P=0.000;(87.4±13.6)min vs.(71.6±13.0)min,t=4.036,P=0.000],术后1个月射血分数低(55.7%±5.3%vs.59.4%±4.6%,t=-2.525,P=0.015)。结论与胸骨正中切口手术相比,第3肋间小切口心脏多瓣膜病变手术在多个方面具有明显的优势。其手术方式安全可靠,能够以较小的创伤获得满意的效果。     

麻醉方式和术后镇痛对上腹部手术后早期呼吸功能影响的初步观察

２０例胆囊切除者分为三组，即硬膜外阻滞组、术中全麻术后硬膜外镇痛组及全麻组。三组病术后早期ＦＶＣ、ＦＦＶ１．０、ＰＦ均明显降低，术后硬膜外镇痛组下降最少。全麻术后早期伴有ＰａＯ２下降及ＰＡ－ａＤＯ２升高，术后早期硬膜外镇痛可改善全麻术后早期通气功能及氧合。     

A randomised,controlled trial of rectus sheath bupivacaine and intrathecal bupivacaine,without or with intrathecal morphine,vs. intrathecal bupivacaine and morphine after caesarean section

We recruited 144 women of whom 131 underwent scheduled caesarean section and were allocated to intrathecal bupivacaine without (46) or with (47) morphine and postoperative rectus sheath bupivacaine; or intrathecal bupivacaine with morphine and postoperative rectus sheath saline (38). We measured postoperative pain with a 10‐point numeric rating scale. The mean (SD) areas under the curve for pain on movement during 48 postoperative hours were 273.5 (63.6), 223.8 (80.7) and 223.8 (80.7), respectively, p = 0.008. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 1. The equivalent values for pain at rest were 160.8 (64.7), 85.8 (79.4) and 82.8 (74.3), respectively, p < 0.001. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 0.98.     

Effect of Anaesthesia on Respiratory Function after Major Lower Extremity Surgery A Comparison between Bupivacaine Spinal Analgesia with Low-Dose Morphine and General Anaesthesia

Postoperative pulmonary function was studied in 16 patients undergoing total hip or knee arthroplasty. Their mean age was 65 years. Half of them received spinal analgesia (22.5 mg bupivacaine + 0.3 mg morphine) and the other half underwent general anaesthesia with halothane-nitrous oxide. Four hours postoperatively, the forced expirogram was maintained in the spinal analgesia group, compared with preanaesthesia measurements. Functional residual capacity (FRC) measured by multiple breath nitrogen washout was reduced by 0.51, as was closing capacity (CC) measured by the bolus technique. The gas distribution index (nitrogen washout delay) was unaltered. The alveolar-arterial oxygen tension difference (PA-ao2) was not significantly altered, but arterial oxygen tension (Pao2) was reduced by 1.7 kPa, and arterial carbon dioxide tension (PaCo2) was increased. No respiratory measurements could be made in the general anaesthesia group 4 h postoperatively, but arterial blood gases were unaltered compared with preanaesthesia values. Eighteen hours postoperatively, forced vital capacity (FVC) was reduced in the spinal analgesia group, FRC and CC remained diminished and the gas distribution index was increased, indicating less efficient gas mixing. Simultaneously, PA-ao2 was increased, and Pao2 remained reduced despite increased alveolar ventilation (lowered PaCo2). In the general anaesthesia group FVC, FRC and CC were also reduced, but the gas distribution index remained at the awake level and blood gases were unaltered. It is suggested that the slight hypoventilation in the spinal analgesia group early after surgery may have contributed to impaired gas distribution and ventilation-perfusion matching later postoperatively.     

A Controlled Study on the Effect of Epidural Analgesia with Local Anaesthetics and Morphine on Morbidity after Abdominal Surgery

A hundred patients scheduled for elective abdominal surgery were randomized to either general anaesthesia (low-dose fentanyl) and systemic morphine for postoperative pain or combined general anaesthesia and epidural analgesia with etidocaine 1.5% intraoperatively (T4-S5) and bupivacaine 0.5% 5 ml/4 h for 24 h and morphine 4 mg/12 h for 72 h. Postoperative pain was better controlled by the epidural regimen (P less than 0.0001). We found no significant reduction in postoperative mortality (6% to 2%), pneumonia (28% to 20%), cardiac dysrhythmia (10% to 5%) and wound complications (14% to 11%) by the epidural analgesic regimen. The incidence of deep venous thrombosis (125I-fibrinogen scan) was 32% after general anaesthesia and low-dose heparin and 34% after epidural analgesia with no prophylactic antithrombotic treatment (P greater than 0.9). Postoperative weight loss and decrease in serum-albumin and serum-transferrin, as well as the reduction in haemoglobin and the need for postoperative transfusions, were similar in the two groups. Convalescence, as assessed by postoperative fatigue, restoration of bowel function (flatus, bowel movement and food intake) and the time until the patients were self-aided at their preoperative level, was not reduced by epidural analgesia. Since 50% of the patients in each group suffered from one or more of the above-mentioned postoperative complications, this epidural regimen was not effective in reducing postoperative morbidity after major abdominal surgery despite the achievement of adequate pain relief.     

Spinal Surgery after Bilateral Subthalamic Stimulation for Patients with Parkinson’s Disease: A Retrospective Outcome Analysis of Pain and Functional Control

Parkinson’s disease (PD) patients often suffer from spinal diseases requiring surgeries, although the risk of complications is high. There are few reports on outcomes after spinal surgery for PD patients with deep brain stimulation (DBS). The objective of this study was to explore the data on spinal surgery for PD patients with precedent DBS. We evaluated 24 consecutive PD patients with 28 spinal surgeries from 2007 to 2017 who received at least a 2-year follow-up. The characteristics and outcomes of PD patients after spinal surgery were compared to those of 156 non-PD patients with degenerative spinal diseases treated in 2013–2017. Then, the characteristics, outcomes, and spinal alignment of PD patients receiving DBS were analyzed in degenerative spinal/lumbar diseases. The mean age at the time of spinal surgery was 68 years. The Hoehn and Yahr score regarding PD was stage 1 for 8 patients, stage 2 for 2 patients, stage 3 for 8 patients, stage 4 for 10 patients, and stage 5 for 0 patient. The median preoperative L-DOPA equivalent daily dose was 410 mg. Thirteen patients (46%) received precedent subthalamic nucleus (STN) DBS. Lumbar lesions with pain were common, and operation and anesthesia times were long in PD patients. Pain and functional improvement of PD patients persisted for 2 years after surgery with a higher complication rate than for non-PD patients. PD patients with STN DBS maintained better lumbar lordosis for 2 years after spinal surgery. STN DBS significantly maintained spinal alignment with subsequent pain and functional amelioration 2 years after surgery. The outcomes of spinal surgery for PD patients might be favorably affected by thorough treatment for PD including DBS.     

The effects of tramadol on postoperative nausea, vomiting and headache after ENT surgery. A placebo-controlled comparison with equipotent doses of nalbuphine and pethidine

Background: Opioids given as adjuncts to balanced inhalational anaesthesia augment postoperative nausea and vomiting (PONV). Tramadol, equipotent to pethidine, does not depress respiration, but can cause an increase in blood pressure and headache via its monoaminergic actions. Nalbuphine, ten times as potent as pethidine, has a ceiling respiratory depressant and ceiling analgesic effect at >0.3 mg · kg^?1. We compared the effects of equipotent doses of tramadol and nalbuphine (3.0 and 0.3 mg · kg^?1, respectively) given as analgesic with induction of anaesthesia on emesis during recovery from anaesthesia and on PONV and headache until 24 h after ENT surgery, using saline (0.2 ml · kg^?1) and an equipotent dose of pethidine (1.5 mg · kg^?1) as controls. Method: The study population (N=281) comprised 4 comparable subgroubs (N=69 to 71 each). Anaesthetic medications were standardised. Emesis during recovery from anaesthesia and nausea, vomiting, retching, headache and administrations of antiemetic and analgesics until 24 h after surgery were recorded. Results: Emesis and antiemetic requirements during recovery from anaesthesia were similar and infrequent in each group, as were the incidences of nausea alone (3 to 5%), vomiting alone (17 to 31%), and nausea with vomiting (10 to 22%) during the first 24 h after surgery. However, any complaint of PONV was least frequent in the saline and pethidine groups (32% and 37%, respectively) and most frequent in the tramadol and nalbuphine groups (49% and 52%, respectively; P<0.05 versus saline, both comparisons; P=NS versus pethidine, both comparisons). The times to onset and severity of PONV were similar in each group, but patients given nalbuphine most frequently (P<0.025) needed rescue antiemetic to treat PONV. Headache occurred with similar frequency in each group. Conclusion: It is concluded that tramadol, nalbuphine and pethidine have similar emetic effect in the doses and manner used, and that tramadol does not increase the incidence of postoperative headache when used as peroperative analgesic.     

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.