外周神经阻滞在单侧大隐静脉曲张手术中的应用

下肢外周神经阻滞适用于髋关节以下的下肢手术,安全性高,并发症少,操作简便,麻醉效果确切,术后镇痛效果好.近年来,神经刺激仪定位技术的临床应用,提高了外周神经阻滞的准确性和阻滞效果.较之传统的椎管内麻醉,具有术中患者生命体征平稳、对胃肠道功能无影响、无脊麻后头痛、术后恶心呕吐,不需术后禁食等优点.我院于2004年9月起,对54例单侧大隐静脉手术分别采用神经刺激仪引导下的外周神经阻滞与硬膜外麻醉方法,观察并比较其麻醉效果.     

超声引导下胸神经阻滞在乳腺手术中的研究进展

正乳腺手术尤其是乳腺癌根治术后常出现中度至重度急性疼痛,急性疼痛与术后慢性疼痛的发生及持续时间密切相关,明显降低术后生活质量[1]。多模式镇痛观点提倡联合应用神经阻滞、非甾体类抗炎药、阿片药物等多种麻醉方法与药物减轻患者疼痛,降低阿片药物用量及相关不良反应。超声定位法的出现,大大提升了麻醉科医师开展外周神经阻滞的技术水平。胸神经(pectoral nerves, Pecs)阻滞是一类新型浅表神经阻滞,其安全性高、镇痛效果好,临床应用日益增     

连续外周神经阻滞的研究进展

连续外周神经阻滞(continuous peripheral nerve blocks,CPNBs)是一种中长效的镇痛方法.与静脉镇痛及硬膜外镇痛相比,CPNBs的镇痛效果更好而不良反应少,增加了患者的舒适度,并能促进术后功能恢复、减少术后慢性疼痛综合征的发生率.大量的实践证明,CPNBs技术用于成人和儿童都同样安全有效,甚至患者在家中也能使用这一技术进行疼痛控制.本文综述CPNBs在定位、注药方法、临床应用范围和并发症等方面的研究进展.     

神经刺激仪引导后入路臂丛神经阻滞的可行性

神经刺激仪引导下臂丛神经阻滞是上肢手术常用的麻醉方法,常规采用肌间沟入路法,该入路穿刺路径较短,不利于术后连续臂丛神经阻滞镇痛的实施,而对于肥胖或强直性脊柱炎患者,肌间沟难以定位,不宜采用.后入路臂丛神经阻滞骨性解剖标志明显,易于定位,且穿刺路径相对较长,有利于术后连续臂丛神经阻滞镇痛时导管的固定[1].本研究拟探讨神经刺激仪引导后入路臂丛神经阻滞的可行性.     

外周神经刺激器辅助定位在小儿臂丛阻滞中的应用

小儿上肢及手部手术常因患儿恐惧及不能说出准确的“异感”而放弃经济有效且有利术后镇痛的臂丛阻滞,而用外周神经刺激器则可使麻醉科医师不依赖患儿的特定信息,使患儿在镇静镇痛状态下接受阻滞。本文拟对小儿在镇静镇痛状态下,用外周神经刺激器辅助定位行臂丛神经阻滞观察。     

神经刺激仪引导下胫神经阻滞用于小儿马蹄足畸形纠正术

外周神经阻滞采用神经刺激仪定位技术在临床应用广泛.但小儿麻醉中使用多限于臂丛神经阻滞.本研究在小儿马蹄足畸形纠正术中采用神经刺激仪引导胫神经阻滞,取得了良好的麻醉效果,并且术后镇痛完善.     

外周区域阻滞与术后镇痛的新观点和新方法

如何提高围术期病人的生活质量是麻醉医生应始终思考的问题之一 ,研究表明手术后疼痛是围术期病人的主要痛苦所在。因此 ,临床麻醉和术后镇痛是一个不可分隔的整体 ,术后镇痛是提高围术期病人生活质量的重要环节 ,理应予以重视 !近 10年来 ,随着临床麻醉条件的改善 ,国内临床麻醉中全身麻醉的比例明显提高 ,区域阻滞麻醉的比例有所下降 ,而国外在临床上全身麻醉十分普及的同时 ,却出现了重视外周区域阻滞的趋势。外周神经阻滞技术通常用于围术期麻醉和镇痛 ,外周神经置管和连续给药技术将外周神经阻滞演变为术后镇痛的有效方法。外周神经阻…     

腰丛-坐骨神经联合阻滞的临床应用

区域神经阻滞如果定位准确、麻醉效果确切,对患者有全身影响小和术后镇痛时间长等优点。近年在穿刺方法和临床应用方面有较大的改进,就腰丛-坐骨神经联合阻滞的应用解剖、神经定位方法特别是神经刺激器的使用、临床适应证、操作方法及术后镇痛进行了综述     

连续肌间沟臂丛神经阻滞术后自控镇痛不同给药方案的临床研究

术后病人自控镇痛（PCA）技术已经广泛应用于临床，外周神经阻滞技术在术后镇痛中具有很大优势，正逐渐受到更多人重视和普遍应用。其中，臂丛神经阻滞术后自控镇痛（PCNA）具有独特的优越性：减轻术后疼痛从而减轻应激反应，利于伤口愈合，使外周血管扩张，利于再植指成活等手外科或血管外科手术成功率。本研究采用“Y”型静脉留置针肌间沟连续臂丛神经阻滞，     

全膝关节置换术后镇痛治疗

充分、有效的术后镇痛是全膝关节置换术(TKR)后功能锻炼的有力保证,直接关系到术后恢复和手术效果.目前TKR术后镇痛策略主要有超前镇痛和多模式复合术后镇痛.多数学者认为外周神经阻滞和硬膜外镇痛的效果更为可靠,而外周神经阻滞的术后并发症少,更为理想.     

Perioperative analgesia with continuous peripheral nerve blocks in children

Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.     

Attenuation of pain in a randomized trial by suppression of peripheral nociceptive activity in the immediate postoperative period

Peripheral neuronal barrage from tissue injury produces central nervous system changes that contribute to the maintenance of postoperative pain. The therapeutic approaches to blocking these central changes remain controversial, because previous studies have not differentiated presurgical interventions from those administered after tissue injury, yet before pain onset. In this study, we evaluated the relative contributions of blockade of nociceptive input during surgery or during the immediate postoperative period on pain suppression. Subjects were randomly allocated to one of four groups: preoperative 2% lidocaine, postoperative 0.5% bupivacaine, both, or placebo injections. General anesthesia was induced and third molars extracted. Pain was assessed over 4 h and at 24 and 48 h. The beta-endorphin in blood samples increased twofold during surgery, which is indicative of activation of the peripheral nociceptive barrage in response to painful stimuli. Pain was decreased in the immediate postoperative period in the bupivacaine groups, whereas it increased in the lidocaine group over time. Pain intensity was less 48 h after surgery in the groups whose postoperative pain was blocked by the administration of bupivacaine, but no effect was demonstrated for the preoperative administration of lidocaine alone. These results in the oral surgery pain model suggest that minimizing the peripheral nociceptive barrage during the immediate postoperative period decreases pain at later time periods. In contrast, blocking the intraoperative nociceptive barrage does not appear to contribute significantly to the subsequent reduction in pain. IMPLICATIONS: Suppression of postoperative pain immediately after surgery attenuates the pain experienced 1 to 2 days after surgery. These findings suggest that pain after minor surgery can be prevented by blocking the development of pain processes that amplify pain for days after surgery.     

Continuous peripheral nerve blocks in children

In recent years, regional anaesthesia in children has generated increasing interest. Continuous peripheral nerve blocks have an important role in the anaesthetic arsenal, allowing effective, safe and prolonged postoperative pain management. Indications for continuous peripheral nerve blocks depend on benefits/risks analysis of each technique for each patient. The indications include surgery associated with intense postoperative pain, surgery requiring painful physical therapy, and complex regional pain syndrome. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous stimulation or ultrasound guidance, appear to facilitate nerve and plexus identification in paediatric patients. Nevertheless, continuous peripheral nerve block may mask compartment syndrome in certain surgical procedure or trauma. Finally, ropivacaine appears to be the best local anaesthetic for continuous peripheral nerve blocks in children, requiring low flow rate with low concentration of the local anaesthetic.     

Perioperative Schmerztherapie

Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. Optimal treatment of patients with peripheral nerve blocks, spinal or epidural analgesia should be treated by a specialized acute pain service. However, only 15?C20% of all surgical cases will be taken care of by such a pain service. Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel.     

Update on intra-articular analgesia

Ambulatory arthroscopic surgery is now an established technique for the diagnosis and operative management of intra-articular lesions but is sometimes associated with moderate to severe postoperative pain. Therefore, adequate postoperative pain relief is an important goal after ambulatory surgery. Conventional techniques using oral analgesics have been a routine, but the last 10 years have seen an explosion of articles on local and regional techniques for pain management. The intra-articular injection of LA and other adjuvants has become commonplace, but evidence as to its efficacy is limited. Local anesthetics injected intra-articularly have shown a weak and short-lasting effect in one systematic review of the literature. Intra-articular morphine has been more promising and appears to be most effective when the postoperative pain is moderate to severe, but whether this is a systematic effect or via peripheral receptors remains unclear. Nonsteroidal anti-inflammatory agents, including ketorolac and tenoxicam, have shown consistent reduction in postoperative pain when injected intra-articularly, but there is some concern regarding delay in bone healing. Clonidine, too, has reduced pain in a majority of the studies, but this reduction in pain intensity is only mild. Other drugs, including neostigmine, steroids, and ketamine have been inadequately studied to offer any definite conclusions.     

Review article: Preventive analgesia: quo vadimus?

The classic definition of preemptive analgesia requires 2 groups of patients to receive identical treatment before or after incision or surgery. The only difference between the 2 groups is the timing of administration of the drug relative to incision. The constraint to include a postincision or postsurgical treatment group is methodologically appealing, because in the presence of a positive result, it provides a window of time within which the observed effect occurred, and thus points to possible mechanisms underlying the effect: the classic view assumes that the intraoperative nociceptive barrage contributes to a greater extent to postoperative pain than does the postoperative nociceptive barrage. However, this view is too restrictive and narrow, in part because we know that sensitization is induced by factors other than the peripheral nociceptive barrage associated with incision and subsequent noxious intraoperative events. A broader approach to the prevention of postoperative pain has evolved that aims to minimize the deleterious immediate and long-term effects of noxious perioperative afferent input. The focus of preventive analgesia is not on the relative timing of analgesic or anesthetic interventions, but on attenuating the impact of the peripheral nociceptive barrage associated with noxious preoperative, intraoperative, and/or postoperative stimuli. These stimuli induce peripheral and central sensitization, which increase postoperative pain intensity and analgesic requirements. Preventing sensitization will reduce pain and analgesic requirements. Preventive analgesia is demonstrated when postoperative pain and/or analgesic use are reduced beyond the duration of action of the target drug, which we have defined as 5.5 half-lives of the target drug. This requirement ensures that the observed effects are not direct analgesic effects. In this article, we briefly review the history of preemptive analgesia and relate it to the broader concept of preventive analgesia. We highlight clinical trial designs and examples from the literature that distinguish preventive analgesia from preemptive analgesia and conclude with suggestions for future research.     

Douleur du membre fantôme : de la physiopathologie à la prévention

First described in 1545, phantom limb pain is a frequent complication after limb amputation, described by 60 to 85% of amputees. Stump pain, phantom limb sensation and phantom limb pain are often combined. Physiopathology is complex and peripheral, medullar and cortical mechanisms are combined. Pharmacological preventive treatments as well as regional anaesthesia techniques have equivalent results. Such treatments must be investigated more precisely as postoperative rehabilitation of amputees mostly depends on pain relief.     

Review article: The role of anticonvulsant drugs in postoperative pain management: a bench-to-bedside perspective

PURPOSE: Anticonvulsant drugs are effective in the treatment of chronic neuropathic pain but were not, until recently, thought to be useful in more acute conditions such as postoperative pain. However, similar to nerve injury, surgical tissue injury is known to produce neuroplastic changes leading to spinal sensitization and the expression of stimulus-evoked hyperalgesia and allodynia. Pharmacological effects of anticonvulsant drugs which may be important in the modulation of these postoperative neural changes include suppression of sodium channel, calcium channel and glutamate receptor activity at peripheral, spinal and supraspinal sites. The purpose of this article is to review preclinical evidence and clinical trial data describing the efficacy and safety of anticonvulsant drugs in the setting of postoperative pain management. SOURCE: A Medline search was performed to retrieve available literature on the basic and clinical pharmacology of anticonvulsant drugs as they pertain to postoperative pain management. PRINCIPAL FINDINGS: Numerous laboratory studies have described analgesic effects of different anticonvulsant drugs in experimental pain models. Furthermore, several recent clinical trials have shown that anticonvulsants may reduce spontaneous and movement-evoked pain, as well as decrease opioid requirements postoperatively. Some early findings suggest further that anticonvulsant drugs may alleviate postoperative anxiety, accelerate postoperative functional recovery and reduce chronic postsurgical pain. CONCLUSION: Given the incomplete efficacy of currently available non-opioid analgesics, and the identified benefits of opioid sparing, anticonvulsant medications may be useful adjuncts for postoperative analgesia. Further research in this field is warranted.     

Continuous peripheral nerve blockade in lower extremity surgery

Peripheral nerve blocks afford numerous benefits for lower extremity surgery. There is growing interest in continuous peripheral nerve blocks, mainly for treatment of postoperative pain, a field that represents a challenge to the anaesthesiologist. This paper seeks to review the efficacy of continuous lower limb blocks for postoperative pain relief. Not only do continuous peripheral nerve blocks afford specificity of analgesic area but current research has shown that they enhance postoperative analgesia and patient satisfaction. New techniques and devices are increasingly appearing, and catheters are constantly being developed and improved; an example being the stimulating catheter, which represents one of the newest advances in this area. The above techniques show that continuous postoperative analgesia with catheters in the lower extremities is not only possible, but indeed provides sustained effective postoperative analgesia, reduces use of opioids, and improves rehabilitation and patient well-being with minimal side-effects. These techniques could prove an alternative to postoperative pain treatment following ambulatory surgery.     

Continuous peripheral nerve blocks in infants and children

This article describes the techniques and clinical efficacy of continuous peripheral nerve blocks in infants and children after orthopedic limb surgery. These techniques are reliable, safe, and easy to perform. They provide efficient pain relief after hand, femoral shaft, knee, or foot surgery. They are as efficient as epidural analgesia or parenteral opioids but induce fewer side effects. They therefore represent good alternatives to treat postoperative pain after limb surgery and should have a place of choice in the armamentarium of each anesthesiologist involved in the management of postoperative pain after pediatric orthopedic surgery. Copyright 2002, Elsevier Science (USA). All rights reserved.