超声引导下连续股神经阻滞联合喉罩下全麻与硬膜外阻滞复合喉罩下全麻用于全膝关节置换术的效果比较

目的 比较超声引导下连续股神经阻滞联合喉罩全麻与连续硬膜外阻滞复合喉罩全麻用于全膝关节置换术的效果.方法 择期行全膝关节置换术的类风湿性关节炎和骨关节炎造成的膝关节破坏患者60例,采用随机数字表法分为2组.Ⅰ组超声引导行连续股神经阻滞联合喉罩下全麻,Ⅱ组在连续硬膜外阻滞复合喉罩下全麻.记录术中和PACU停留期间的生命体征用药情况.记录术后48 h内PAC药物用量和恶心呕吐、低血压的发生情况,术后VAS评分和患者总体满意度评价.结果 2组一般资料比较无显著差异（P＞0.05）,2组患者术后6h、12 h、24 h、48 hVAS评分比较无显著差异（P＞0.05）.Ⅰ组术中截骨后即刻平均动脉压、心率与Ⅱ组比较有显著差异（P＜0.05）,其他效果基本一致,Ⅱ组术后恶心呕吐,低血压发生率比Ⅰ组高（P＜0.05）.结论 两种方式均能满足术后镇痛需要,但Ⅰ组并发症少、风险低,操作简单直观,患者舒适度高.     

经臀下入路连续坐骨神经阻滞在跟骨骨折患者术后镇痛中的应用

目的探讨0．2％罗哌卡因经臀下入路连续坐骨神经阻滞用于跟骨骨折术后镇痛的效果及安全性。方法纳入2012年5月-2013年1月40例择期行跟骨骨折切开复位内固定术患者，随机分为连续坐骨神经阻滞组（CSB组）和静脉自控镇痛组（PCIA组），每组20例。CSB组行经臀下入路的连续坐骨神经阻滞置管，术后连接镇痛泵持续泵注0．2％罗哌卡因进行连续镇痛。PCIA组术后采用镇痛泵进行静脉自控镇痛。观察术后2、8、24、48h静止和运动时疼痛评分和镇静评分，记录患者术后其他镇痛药物使用情况、患者及医生满意度和不良反应发生情况。结果CSB组术后各时点视觉模拟评分（VAS）（静止和运动）均明显低于PCIA组，差异有统计学意义（P〈0．005）；术后镇痛药物的使用量均明显低于PCIA组，差异具有统计学意义（P〈0．05）；患者及医生满意度明显高于PCIA组，差异具有统计学意义（P〈0．05）。结论与静脉自控镇痛相比，0．2％罗哌卡因经臀下入路连续坐骨神经阻滞可为跟骨骨折术后提供更加满意的镇痛效果，安全性高，值得临床推广。     

Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Hip arthroscopy is a minimally invasive alternative to open hip surgery. Despite its minimally invasive nature, there can still be significant reported pain following these procedures. The impact of combined sciatic and lumbar plexus nerve blocks on postoperative pain scores and opioid consumption in patients undergoing hip arthroscopy was investigated. A retrospective analysis of 176 patients revealed that compared with patients with no preoperative peripheral nerve block, significant reductions in pain scores to 24 hours were reported and decreased opioid consumption during the post anesthesia care unit (PACU) stay was recorded; no significant differences in opioid consumption out to 24 hours were discovered. A subgroup analysis comparing two approaches to the sciatic nerve block in patients receiving the additional lumbar plexus nerve block failed to reveal a significant difference for this patient population. We conclude that peripheral nerve blockade can be a useful analgesic modality for patients undergoing hip arthroscopy.     

全膝关节置换应用股神经阻滞镇痛与自控静脉镇痛的系统评价

背景：目前对全膝关节置换围手术期采用何种镇痛方法的效果差异存在争议. 目的：系统评价全膝关节置换术中应用股神经阻滞镇痛与患者自控静脉镇痛的疗效和安全性. 方法：全面搜索国内外关于全膝关节置换中应用股神经阻滞镇痛和患者自控静脉镇痛的随机对照研究资料,按照既定的纳入、排除标准,核定检出符合评价标准的文献,提取所需研究数据,采用RevMan 5.0.18软件进行Meta分析.评价指标包括术后24,48 h静息和活动时的目测类比评分、恶心呕吐胃肠道症状发生率、嗜睡等镇静过度发生率以及患者满意率. 结果与结论：纳入随机对照研究19篇,样本共计952膝,股神经阻滞组和患者自控静脉镇痛组分别为481膝和471膝.荟萃分析加权后,股神经阻滞与患者自控静脉镇痛相比,术后24,48 h静息和活动目测类比评分均较低（P 〈0.05）,无论是单次股神经阻滞还是连续股神经阻滞,差异均有显著性意义.在并发症发生率方面,股神经阻滞术后恶心呕吐及嗜睡发生率低于患者自控静脉镇痛（P 〈0.05）.结果提示,全膝关节置换术中采用股神经阻滞镇痛,无论是镇痛效果还是并发症发生率都优于患者自控静脉镇痛,且股神经阻滞镇痛患者满意度较高.但二者间的比较仍需大规模多中心的随机对照试验来进一步研究.     

Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache: Twenty case reports and a review of the literature

BACKGROUNDAccidental dural puncture (ADP) and subsequent post-dural puncture headache (PDPH) remain common complications of epidural procedures for obstetric anesthesia and analgesia. No clear consensus exists on the best way to prevent PDPH after ADP.CASE SUMMARYWe report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch (HES) to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures. ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section (CS) and in eleven parturients receiving labor analgesia. An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients. After CS, the epidural catheter was used for postoperative pain relief over a 48-h period. After delivery in eleven cases, epidural infusion was maintained for 24 h. Thereafter, 15 mL of 6% HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal. None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.CONCLUSIONAn incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.     

A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study. (University of Michigan Medical Center, Ann Arbor, MI) Anesth Analg 2000;91:781–786.

Carotid endarterectomy may be preformed by using cervical plexus blockade with local anesthetic supplementation by the surgeon during surgery. Most practitioners use either a superficial cervical plexus block or a combined (superficial and deep) block, but it is unclear which offers the best operative conditions or greatest patient satisfaction. This study compared the 2 techniques in 40 patients undergoing carotid endarterectomy. The patient randomly received either a superficial or a combined cervical plexus block. Bupivacaine 0.375% to a total dose of 1.4 mg/kg was used. The main outcome measure was the amount of supplemental lidocaine 1% used by the surgeon. Subsidiary outcome measures were postoperative pain score, sedative and analgesic requirements before and during surgery, and postoperative analgesic requirements. Median supplemental lidocaine requirements were 100 mg in the superficial block group and 115 mg in the combined block group. These differences were not statistically significant. There was no significant difference in the number of patients needing postoperative analgesia between the groups in the 24 h after surgery. The median time to first analgesia in the superficial block group was 150 min. more than in the combined block group, but this difference, although large, was not statistically significant. No significant differences were found between the anesthetic techniques studied. Comment by Alan Kaye, M.D. Carotid endarterectomy surgery can be performed with regional or general anesthesia. It is probable that a substantial majority of CEAs performed in North America are performed under general anesthesia. Debate over choice of regional versus general anesthesia persists because of various studies of risks and benefits. Each type of anesthesia has its own advantages and disadvantages, which must be considered when choosing the optimal anesthetic for patients. Regional anesthetic techniques available include local infiltration, superficial and deep cervical plexus block, a combination of these with or without contralateral superficial plexus, and cervical epidural anesthesia. This prospective, randomized, double‐blinded study compared superficial versus combined (superficial and deep) cervical plexus block in 40 patients. Outcomes were measured by supplemental local anesthetic used by the surgeon, postoperative pain scores, and sedative and analgesic requirements before, during, and postoperatively. The results showed no significant difference in either study group. Therefore, this small study suggests that superficial block should be preferred in as much that it is relatively easy to do and the potential side‐effects are far less than deep cervical block. Larger studies are warranted in this difficult population of patients.     

Peripheral nerve blocks in the outpatient surgery setting

Peripheral nerve blocks involve injecting local anesthesia near or around a nerve or nerve plexus. This form of anesthesia allows surgeons to perform more complex surgeries and provides extended postoperative analgesia for patients. Patients experience reduced postoperative pain and length of hospital stay and increased satisfaction with the outcome of surgery because they are less likely to experience adverse effects. Use of peripheral nerve blocks in an outpatient setting is becoming more common and has increased the perioperative nurse's patient care responsibilities. The nurse must perform a preblock assessment and assist the anesthesia professional with administration of the block. Major responsibilities of the nurse include identifying and managing potential adverse effects (eg, pneumothorax, toxicity) associated with block administration and patient discharge education.     

罗哌卡因复合舒芬太尼用于臂丛神经阻滞术后镇痛的效果评价

目的：评价舒芬太尼复合罗哌卡因用于臂丛神经阻滞术后镇痛的效果。方法：选择60例在臂丛神经阻滞复合全麻下行择期肱骨近端骨折切开复位内固定术并行连续臂丛神经阻滞术后镇痛的患者,随机分为两组：观察组（n=30）用药为0.2μg.mL^-1舒芬太尼和0.2%罗哌卡因,对照组（n=30）为0.2%罗哌卡因。分别记录两组用药量、静息和运动VAS评分、PONV及患者满意度。结果：两组间静息和运动VAS评分、PONV及患者满意度差异均无统计学意义。结论：复合0.2μg.mL^-1的舒芬太尼不能增强0.2%罗哌卡因连续臂丛神经阻滞术后镇痛的镇痛效果。     

Effects of intrathecal fentanyl on duration of bupivacaine spinal blockade for outpatient knee arthroscopy.

The purpose of this study was to determine if intrathecal fentanyl speeds the onset and prolongs the duration of sensory and motor block, prolongs the duration of postoperative analgesia, or increases the incidence of adverse effects in patients undergoing spinal anesthesia for outpatient knee arthroscopy. Fifty patients were randomized to receive 12 mg of hyperbaric bupivacaine 0.75% with 25 micrograms (0.5 mL) of fentanyl (group 1) or 12 mg of hyperbaric bupivacaine 0.75% with 0.5 mL of preservative-free normal saline (group 2). One-tailed t tests were used to determine differences in onset and duration of sensorimotor block and postoperative analgesia. No differences were found in onset and duration of sensory or motor block. Group 1 experienced significantly better postoperative analgesia lasting more than 3 hours longer than analgesia for group 2. Group 1 demonstrated significantly more pruritus, but there were otherwise no differences. We conclude that fentanyl does not enhance the onset and duration of sensory or motor block produced by 12 mg of intrathecal bupivacaine. Fentanyl, however, prolongs postoperative analgesia and increases the risk of pruritus.     

超声引导下臂丛神经阻滞术后留置导管对肘关节骨折患者术后镇痛及功能锻炼的影响

目的探讨超声引导下臂丛神经阻滞术后留置导管对肘关节骨折患者术后镇痛及功能锻炼的影响。方法将60例行臂丛神经阻滞术后的肘关节骨折患者随机分为对照组与研究组,各30例。对照组术后留置导管采用外周神经刺激器引导,研究组采用超声引导。比较两组的临床效果。结果研究组的置管次数、手术时间、药液渗漏发生率、辅助镇痛率、罗哌卡因用量、运动阻滞恢复时间、术后苏醒时间、并发症发生率均优于对照组(P<0.05)。术后1、6、24、48 h,研究组的VAS评分均低于对照组(P<0.05)。术后24、48、72 h,研究组的Broberg和Morrey评分均高于对照组(P<0.05)。结论超声引导下臂丛神经阻滞术后留置导管应用于肘关节骨折中的效果显著,可提高镇痛效果,有利于患者术后功能锻炼。     

Feasibility of an infraclavicular block with a reduced volume of lidocaine with sonographic guidance.

OBJECTIVE: A successful brachial plexus block requires a large volume of a local anesthetic. Sonography allows reliable deposition of the anesthetic around the cords of the brachial plexus, potentially lowering the anesthetic requirement. METHODS: Fifteen sonographically guided infraclavicular blocks were performed in 14 patients with 2% carbonated lidocaine with epinephrine through a 17-gauge Tuohy needle. The amount of lidocaine injected at several points around each cord was based on satisfactory spread observed sonographically. A 19-gauge catheter was then placed with its tip between the posterior cord and axillary artery, and tip position was confirmed by observing the spread of 1 to 2 mL of injected air. Lidocaine was injected through the catheter if necessary to prolong the blocks. RESULTS: Surgery was performed in all patients without general anesthesia, rescue blocks, or infiltration. A heroin user was given an additional 50 microg of fentanyl before the block. One patient required 5 mL of lidocaine through the catheter for an incomplete radial nerve block 5 minutes after initial injection. Seven patients received additional midazolam (mean, 2.5 mg) for alleviation of anxiety despite excellent blocks. The mean +/- SD volume of lidocaine for the initial block was 16.1 +/- 1.9 mL (4.2 +/- 0.9 mg/kg). In 4 patients, additional lidocaine 1 hour after an initial successful block increased the total volume to 19.5 +/- 7.1 mL (5 +/- 1.9 mg/kg). The mean times to perform the block, onset of the block, and achieving surgical anesthesia and the duration of surgery were 10.8 +/- 3.3, 2 +/- 1.3, 5.9 +/- 2.6, and 92.7 +/- 54.4 minutes, respectively. CONCLUSIONS: A successful infraclavicular block in adults with 14 mL of lidocaine is feasible with the use of sonography. The reduced volume does not seem to affect the onset but shortens the duration of the block.     

Tunneled epidural catheters for prolonged analgesia in pediatric patients. (Stanford University, Stanford, CA) Anesthesia and Analgesia 2001;92:1432–1438.

The charts of 25 patients with prolonged pain that was unresponsive to conventional opioid therapy and who received thoracic, lumbar, or caudal tunneled epidural catheters between 1995 and 1999 were reviewed for efficacy and catheter‐related complications. Tunneled epidural catheters were effective in providing extended analgesia in all subjects. In 14 patients with chronic pain, cumulative 48‐hour enteral and parenteral opioid requirements were reduced or eliminated after catheter insertion. Catheters remained in place for a median of 11 days until there was no further need for parenteral analgesia (n = 15), death because of the underlying disease (n = 6), accidental removal (n = 2), or possible infection (n = 2). No serious local or systemic complications occurred related to this technique. Five patients were discharged from the hospital with the catheter for home analgesic therapy. The use of a percutaneously inserted, subcutaneously tunneled epidural catheter is safe, effective, and provides pain relief in situations in which conventional analgesic therapy either fails or is impractical. The technique is one that may be of great value to children suffering from pain. Comment by Alan David Kaye, M.D., Ph.D., Amr Hegazi, M.D. This retrospective study assessed the safety, efficacy, complications, indications, and duration of use of subcutaneously tunneled lumbar, thoracic and caudal epidural catheters in pediatric patients with prolonged pain. The authors examined a total of 25 patients hospitalized for treatment of acute pain caused by trauma as well as chronic pain resulting from end‐stage cancer or cystic fibrosis. The catheters were introduced under either local anesthesia with sedation or general anesthesia after obtaining informed parental consent. Epidural catheters were inserted percutaneously, then tunneled subcutaneously away from the insertion site to bring the catheter exit site to the anterior abdominal and thoracic, posterior superior iliac crest to decrease the risk of potential infection and chance of catheter dislodgement. Tunneled catheters were effective in providing extended analgesia in all patients. None of the acutely ill patients required supplemental enteral or parenteral opioids while pediatric patients with chronic pain had dramatic decrease or elimination of opioid needs. Two of these patients had accidental removal of the catheter. One patient had postoperative fever with possible presence of infection and another patient developed cellulites at the catheter exit site. Both the catheter and wound site were sterile on bacterial cultures. The clinical relevance of routine microbiological culturing of epidural catheters in acute pain management has been evaluated by Simpson et al. It was concluded that a significant proportion of catheter tips can be positive. This suggests that colonization of the skin at the insertion site and subsequent contamination of the tip upon removal of the catheter is a concern and strict sterile aseptic techniques should be practiced by the anesthesiologist. This is an interesting article because at most institutions, pediatric pain and certainly critically ill children are clearly undermanaged. The small size of the study group, however, enables us to appropriately define the risk of infection for long‐term catheter placement (up to 240 days in this article). Also accidental catheter dislodgement especially on patients discharged home with an epidural catheter remains a concern.     

肋间神经阻滞联合静脉自控镇痛对胸腔镜手术患者术后镇痛效果的观察

目的：观察肋间神经阻滞联合静脉自控镇痛对电视辅助胸腔镜手术患者术后的镇痛效果。方法：28例美国麻醉医师学会（ASA）分级Ⅰ-Ⅱ级、年龄19-65岁、无慢性疼痛史、择期行电视辅助胸腔镜手术的胸外科患者。患者随机分为2组：肋间神经阻滞联合静脉自控镇痛组（INB＋PCIA组）和静脉自控镇痛组（PCIA组）。2组患者在手术结束前由胸外科医师在胸腔镜直视下在放置胸腔引流管的肋间和上下各一肋间行肋间神经阻滞,INB＋PCIA组用0.375%罗哌卡因,PCIA组给予0.9%氯化钠液。所有患者均采用芬太尼静脉自控镇痛。随访患者术后4h、24h和48h在平静状态和躯体活动（如咳嗽）时的切口疼痛情况。疼痛评分采用视觉模拟评分法（VAS评分）。记录患者术后4h、24h和48h静脉自控镇痛芬太尼累积用量和术后恶心、呕吐的发生率。观察患者术后有无肋间神经阻滞引起的并发症。结果：2组患者年龄、性别和术后胸腔引流管放置数量均无显著差异。INB＋PCIA组患者在术后4h静息状态、躯体活动状态和24h躯体活动状态时的VAS评分显著低于PCIA组（P〈0.01）。2组患者在术后24h静息状态和48h静息状态、躯体活动时的VAS评分均无显著差异。INB＋PCIA组术后静脉镇痛所需芬太尼累积剂量显著低于PCIA组（P〈0.05）。PCIA组有2例患者需术后追加芬太尼,INB＋PCIA组无患者术后追加麻醉性镇痛药,2组间无显著差异（P〉0.05）。2组患者术后恶心、呕吐发生率无显著差异（P〉0.05）。2组患者均无肋间神经阻滞引起的并发症。结论：用0.375%罗哌卡因行肋间神经阻滞联合静脉自控镇痛的镇痛方式能减轻胸腔镜手术患者术后24h内的急性疼痛,并且能减少静脉自控镇痛阿片类药物的累积用量。     

A Multicenter,Randomized, Double‐Blind,Placebo‐Controlled Trial of Intravenous Ibuprofen (IV‐Ibuprofen) in the Management of Postoperative Pain Following Abdominal Hysterectomy

Background: Ibuprofen and other nonsteroidal anti‐inflammatory drugs are widely used to block pain and inflammation in a variety of settings. Contrarily, opioid analgesia does not block the inflammatory component of pain and the use of these agents can be accompanied by serious side effects. We conducted a multicenter, randomized, double‐blind, placebo‐controlled trial to evaluate the safety and efficacy of intravenous ibuprofen (IV‐ibuprofen) as a postoperative analgesic. Methods: A total of 319 patients were randomly assigned in a 1:1 ratio to receive 800 IV‐ibuprofen or placebo every 6 hours; in addition patients had access to morphine at a dose of 1–2 mg every 5 minutes. The primary outcome measure was median morphine consumption within the first 24 hours following surgery. Results: During the first 24 hours of treatment, the median morphine requirement was reduced by 19% (P ≤ 0.001) and resulted in a significant reduction in pain at rest (AUC, 6 to 24 hours and 12 to 24 hours, P < 0.001) and pain with movement (AUC, 6 to 24 hours, P = 0.010 and 12 to 24 hours, P ≤ 0.001) as measured by the visual analog scale (VAS) in patients receiving 800 mg IV‐ibuprofen compared to placebo. Time to ambulation was significantly faster (P = 0.018) in the IV‐ibuprofen treated group, as well. Similar treatment‐emergent adverse events occurred across both study groups and there was no difference in the overall incidence of these events. Conclusion: This study demonstrated that IV‐ibuprofen is an effective analgesic medication that is safe and well tolerated when administered as an 800 mg dose every 6 hours in patients undergoing total abdominal hysterectomy surgery.     

单次股神经联合坐骨神经阻滞与术中关节腔周围鸡尾酒注射镇痛在全膝关节置换术后镇痛效果比较

【目的】探讨单次股神经联合坐骨神经阻滞与术中关节腔周围鸡尾酒注射镇痛在全膝关节置换（total knee arthroplasty,TKA）术后镇痛效果。【方法】选择因单侧膝关节骨性关节炎行TKA且ASAⅠ～Ⅱ级的患者70例,按数字法随机分为两组,每组35例,术后单次股神经联合坐骨神经阻滞为A组、术中关节腔周围鸡尾酒注射镇痛为B组。两组手术麻醉方式均采用腰麻联合硬膜外麻醉方法,术后采用视觉模拟（VAS）评分法评估患者疼痛程度、患肢肌力;记录术后额外镇痛药物氯诺昔康总用量和镇痛相关并发症等;在术后2周、1个月、3个月、6个月的随访中,依照膝关节学会评分系统（KSS）对两组患者膝关节功能进行评估比较。【结果】在术后4h、6h、12h、24h、36h、48h静息状态VAS疼痛评分A组均显著低于B组（P〈0．05）;术后24h、36h、48h进行膝关节持续被动活动（CPM）时累计氯诺昔康镇痛药用量A组均较B组低（P〈0．05）;A组术后尿潴留、皮肤瘙瘁、恶心呕吐等不良反应也均显著低于B组（P〈0．05）;两组术后2周、1个月、3个月、6个月患膝膝关节功能评估比较差异无统计学意义（P〉0．05）。【结论】单次股神经联合坐骨神经阻滞在TKA术后镇痛优于术中关节腔周围鸡尾酒注射镇痛,不良并发症低于术中关节腔周围鸡尾酒镇痛。单次股神经联合坐骨神经阻滞为TKA术后镇痛安全、有效的方法。     

神经刺激器引导用于臂丛神经阻滞及术后镇痛研究

目的 观察神经刺激器定位下经斜角肌间沟留置导管用于持续臂丛神经阻滞及术后镇痛的临床效果和可行性。方法 ASAⅠ～Ⅱ级上肢手术患者60例。随机分为套管针组（A组）和留置导管组（B组），每组30例。A组患者用20G静脉穿刺套管针行常规方法臂丛神经阻滞留置，B组患者在周围神经刺激器引导下穿刺置入专用的柔软导管，手术结束后两组患者均连接一电子镇痛泵行持续术后臂丛神经阻滞镇痛。结果 术中需辅助用药患者两组无统计学差异（P〉0．05）。A组患者术后镇痛失败率达23．3％，B组无镇痛失败患者，两组比较差异有显著性（P〈0．05）。剔除A组镇痛失败患者后，两组患者术后48h内的VAS评分、Ramsay评分和PCA按压次数无统计学差异（P〉0．05）。结论 周围神经刺激器精确引导下经斜角肌间沟留置导管行臂丛神经阻滞和持续术后镇痛是一种可行性好、镇痛效果确切、不良反应少的方法。     

Benefits and risks of granisetron versus ramosetron for nausea and vomiting after breast surgery: a randomized, double-blinded, placebo-controlled trial

Women undergoing general anesthesia for breast surgery are at particular risk of postoperative nausea and vomiting. In a randomized, double-blinded, placebo-controlled trial, 90 patients scheduled for breast surgery, aged 33-63 years, received intravenously placebo, 3 mg granisetron, or 0.3 mg ramosetron (n = 30 of each) at the end of surgical procedure. A standard general anesthetic technique and postoperative analgesia were used. Emetic episodes and safety assessment were performed during 0-24 hours and 24-48 hours after anesthesia. The rate of patients experiencing emetic symptoms (nausea, retching, vomiting) 0-24 hours after anesthesia was 17% with granisetron (P = 0.013) and 10% with ramosetron (P = 0.002) compared with placebo (47%); the corresponding rate 24-48 hours after anesthesia was 27% (P = 0.032) and 7% (P = 0.001), compared with placebo (53%). In the 24-48 hours after anesthesia, there were fewer emetic episodes in patients who had received ramosetron than in those who had received granisetron (P = 0.039). The severity of nausea was less in patients receiving ramosetron than in those receiving granisetron (P = 0.044). Zero to 24 hours after anesthesia, no difference in the rate of patients having emetic symptoms and the severity of nausea was observed between the granisetron and ramosetron groups. The most common reported adverse events were headache and dizziness, and there were no difference in the incidence of adverse events due to the study drug among the 3 groups. In conclusion, prophylactic therapy with ramosetron is more effective than that with granisetron for the long-term prevention of postoperative nausea and vomiting in women undergoing general anesthesia for breast surgery.     

Incidence of Urinary Retention in Patients with Thoracic Patient-Controlled Epidural Analgesia (TPCEA) Undergoing Thoracotomy

Up to 100% of patients treated with epidural analgesia can experience urinary retention, which may be related to dermatomal level of the epidural block, epidural medication, and surgical procedure. This study was designed to identify the incidence of urinary retention in patients who receive thoracic patient-controlled epidural analgesia (TPCEA) after thoracotomy. Forty-nine patients were enrolled and received epidural infusion of ropivacaine 0.2% or mixture of bupivacaine 0.1% with hydromorphone 0.015 mg/mL. Epidural catheter placement level was verified by chest X-rays. Indwelling urinary catheters were removed between 12 and 48 h after surgery when no longer required for fluid monitoring. Four hours later, patients were assessed for urinary retention using bladder ultrasound. Residual bladder volume was recorded, and urinary retention was defined as an inability to void or a bladder volume of greater than 600 mL at 4 h. Twenty-four hours after the catheter removal, patients completed a questionnaire to assess their perception of the indwelling catheter before and after its removal. Five participants (～10%) with epidural catheters between T3 and T5 with bupivacaine/hydromorphone epidural solution were recatheterized. No association was established between catheter level, drug type, infusion rate, and urinary retention. Although 76% of patients did not report any physical discomfort with the indwelling urinary catheter, 66% felt relief after its removal and 18% did not ambulate with the inserted urinary catheter. The incidence of postoperative urine retention was low (10%), indicating that unless required for other purposes, indwelling urinary catheters may be removed between 12 and 48 h after surgery while receiving TPCEA.     

Nerve stimulator‐assisted femoral nerve block in the emergency department

Objective : To describe the technique of femoral nerve block using a nerve stimulator to locate the nerve, and to report the success rate of its use by junior and senior doctors in the emergency department. Method : Standardized protocol and patient selection criteria were formulated for the performance of femoral nerve block on patients with femoral neck or shaft fractures using a nerve stimulator to locate the femoral nerve and confirm deposition of local anaesthetic agent close to the femoral nerve. Femoral nerve blockade was assessed before and after femoral nerve block by testing for altered sensation in the cutaneous distribution of the femoral nerve. Pain was assessed before and after femoral nerve block using a visual analogue scale. The use of supplementary analgesics was recorded. Results : A successful femoral nerve block was obtained with the nerve stimulator in 19 of 22 attempts (86%) at femoral nerve block. Success was unrelated to seniority of staff. Femoral nerve block was the only analgesia required in 17 patients (77%). Femoral nerve block was the only analgesia required for 100% for femoral shaft fractures and 75% and 73%, respectively, for extra‐capsular and intracapsular fractures of the femoral neck. Conclusion : The femoral nerve was accurately located using the nerve stimulator irrespective of seniority of staff performing the procedure. Femoral nerve block using the nerve stimulator was effective analgesia for femoral shaft fractures and the majority of both intra‐ and extra‐capsular femoral neck fractures.     

超声引导下肋间神经阻滞联合全麻对乳腺癌手术的麻醉效果及术后镇痛的影响

目的观察超声引导下肋间神经阻滞联合全麻对乳腺癌改良根治术麻醉效果及术后镇痛的影响。方法择期行乳腺癌改良根治术的患者60例,ASAⅠ^Ⅱ级,随机分为A组和B组,每组30例。A组全麻诱导前先行患侧超声引导下的肋间神经阻滞,B组直接行全麻诱导。术中根据BIS、血压及心率调节全麻药的泵注速度,手术结束时记录丙泊酚和瑞芬太尼的用量及全麻后患者的苏醒时间。患者的术后镇痛A组采用超声引导下的肋间神经阻滞,B组应用静脉泵术后镇痛,观察术后2 h、4 h、8 h、12 h、24 h的镇痛效果、镇静程度及术后并发症的情况。结果 A组与B组相比丙泊酚、瑞芬太尼的用量明显减少以及苏醒时间明显缩短,差异有统计学意义(P<0.01或P<0.05)。A组术后2、4 h的VAS评分与B组比较明显降低,差异有统计学意义(P<0.05),8 h、12 h、24 h的VAS评分相比差异无统计学意义(P>0.05)。A组术后2 h、4 h、8 h、12 h、24 h的镇静评分与B组相比降低,差异有统计学意义(P<0.05)。A组患者仅有2例发生恶心呕吐,未发生皮肤瘙痒、穿刺部位血肿、气胸等不良反应和并发症;B组有9例发生恶心呕吐,6例发生皮肤瘙痒,与A组发生率相比差异有统计学意义(P<0.05)。结论超声引导下肋间神经阻滞可增强全麻的麻醉效果,减少麻醉药的用量,延长术后镇痛时效。