不同浓度罗哌卡因术后臂丛神经镇痛效果的观察

目的比较三种不同浓度罗哌卡因伍用吗啡和利多卡因用于上肢手术后臂丛神经镇痛的效果.方法 90例择期上肢手术病人随机分为0.30%罗哌卡因组(Ⅰ组)(含罗派卡因75 mg、吗啡1 mg、利多卡因200 mg、生理盐水15 ml),0.25%罗派卡因组(Ⅱ组)(含罗派卡因75 mg、吗啡1 mg、利多卡因200 mg、生理盐水20 ml),20%罗哌卡因组(Ⅲ组)(含罗派卡因75 mg、吗啡1 mg、利多卡因200 mg、生理盐水25 ml),术后臂丛神经镇痛(PCRA)负荷剂量15 ml,总剂量15 ml/24h,镇痛时间约50 h.以VAS评分比较三组术后PCRA镇痛效果,Bromage评分评定运动阻滞情况.结果术后6、12、24、48h VAS评分,Ⅲ组显著高于Ⅰ、Ⅱ组,Bromage评分Ⅰ组显著高于Ⅱ、Ⅲ组.无明显不良反应.结论 0.25%罗哌卡因复合吗啡和利多卡因对上肢手术病人术后镇痛效果确切,适合临床应用.     

丁丙诺啡复合局麻药用于臂丛神经阻滞的临床观察

目的：探讨丁丙诺啡复合局麻药用于臂丛神经阻滞对镇痛效果的影响。方法：将40例各类上肢手术患者随机分为实验组（Ⅰ组）和对照组（Ⅱ组），Ⅰ组丁丙诺啡3μg／k＋2％利多卡因10ml＋0.75％布比卡因10ml，Ⅱ组利多卡因10ml＋0.75％布比卡因10ml，比较两组的起效时间、痛觉消失时间、阻滞不全比例、镇痛持续时间。结果：两组在起效时间和痛觉完全消失时间差异无显著性（P〉0.05），Ⅰ组镇痛时间比Ⅱ组明显延长，经t检验，组间比较差异有显著性（P〈0.01）。Ⅱ组术后有超过半数需要肌注杜冷丁止痛，而Ⅰ组仅2例术后应用杜冷丁。结论：丁丙诺啡复合局麻药用于臂丛神经阻滞能够延长麻醉维持时间，对术后镇痛有明显效果。     

局部麻醉剂加小剂量吗啡臂丛神经阻滞在上肢术后镇痛效果的观察

目的:观察局部麻醉剂加小剂量吗啡臂丛神经阻滞在上肢术后镇痛的效果。方法:将52例ASAⅠ～Ⅱ级在肌间沟臂丛神经阻滞下行上肢手术的患者,随机均分为A、B两组。A组在局麻药内加吗啡4mg;B组术毕将吗啡4 mg由臂丛神经注入。观察两组术后镇痛效果及不良反应。结果:A组综合镇痛质量优于B组,镇痛时间长于B组(P<0.05);A、B两组恶心发生率分别为12.5%和16.7%,皮肤瘙痒发生率分别为8.3%和12.5%,两组差异无显著性。结论:将局部麻醉剂加小剂量吗啡术前臂丛神经阻滞在上肢术后的镇痛效果明显优于术后注射吗啡者。     

地佐辛超前镇痛用于锁骨下臂丛神经阻滞的效果评价

目的:观察地佐辛超前镇痛用于臂丛神经阻滞的效果及对术后疼痛的影响。方法:将美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级、行锁骨下臂丛神经阻滞的60例手术患者随机分为3组,每组20例。A组将地佐辛5 mg与局部麻醉药(0.375%罗哌卡因20 mL+1%利多卡因15 mL+1∶20万肾上腺素1 mL)混合用于臂丛神经阻滞。B组于术前15 min静脉注射地佐辛5 mg,联合局部麻醉药(同A组);C组仅行锁骨下臂丛神经阻滞,局部麻醉药同A组。记录麻醉起效时间,手术时间,麻醉后1 h及术后4、8、12、24、36、48 h的疼痛视觉模拟评分(VAS),术后镇痛持续时间(术毕至术后VAS3分的时间),不良反应。结果:A组麻醉起效时间低于B、C组(P0.05)。A、B组术后8 h时的VAS明显低于C组(P0.05);A组术后12、24 h时的VAS明显低于B、C组(P0.05);3组麻醉后1 h及术后4、36、48 h时的VAS差异无统计学意义(P0.05)。术后镇痛持续时间为A组B组C组,差异有统计学意义(P0.05);A组和B组不良反应发生率差异无统计学意义(P0.05)。结论:地佐辛超前镇痛效果确切,能够延长术后镇痛时间,且不良反应少。     

术后硬膜外镇痛对胃肠动力的影响

目的:探讨术后硬膜外镇痛对胃肠动力的影响。方法:84例ASAⅠ～Ⅱ级、择期手术患者随机分为3组:吗啡组30例、芬太尼组30例和对照组24例。吗啡组:术毕镇痛泵吗啡用量5～10mg(50～100μg/ml);芬太尼组:术毕镇痛泵芬太尼用量0.3～0.5mg(3～5μg/ml);对照组:术毕未用镇痛泵;使用镇痛泵设定均为2ml/h、48h后拔除。观察3组患者术后胃排空(胃肠蠕动)时间、术后第1次排气排便时间及术后住院时间。结果:胃排空时间:吗啡组为(49.5±10.82)h,芬太尼组为(26.3±6.84)h,对照组为(27.4±5.43)h;吗啡组与芬太尼组、对照组比较,有显著性差异(P<0.05)。术后第1次排气排便时间:吗啡组为(56.7±11.40)h,芬太尼组为(33.6±5.86)h,对照组为(31.5±6.57)h;吗啡组与芬太尼组、对照组比较,有显著性差异(P<0.05)。结论:术后应用硬膜外镇痛吗啡组患者的胃肠动力恢复延缓。     

低温低浓度利多卡因臂丛神经阻滞用于肩关节复位临床观察

目的:观察低温低浓度利多卡因臂丛阻滞用于肩关节复位的临床效果及不良反应.方法:117例ASA Ⅰ～Ⅱ级肩关节脱位患者随机分为3组.低温低浓度组(A组)39例应用(4±1)℃、质量分数1.0%利多卡因20 mL臂丛神经阻滞; 常温常用浓度组(B组)39例应用(24±1)℃、质量分数1.5%利多卡因20 mL臂丛神经阻滞;常温低浓度组(C组)39例应用(24±1)℃、质量分数1.0%利多卡因20 mL臂丛神经阻滞.比较3组麻醉起效时间、阻滞满意度,术后观察时间及不良反应.结果:A组与B组麻醉起效时间较C组短(P<0.05),阻滞满意度优于C组(P<0.05),A组术后观察时间较B组短(P<0.05),不良反应发生率较B组低(P<0.05).结论:低温低浓度利多卡因臂丛神经阻滞用于肩关节复位安全有效.     

曲马多或吗啡复合布比卡因术后PCEA效果及不良反应探讨

目的 :旨在探讨曲马多或吗啡复合低浓度布比卡因作PCEA的镇痛效果和不良反应。方法 :随机选取 12 0例术后PCEA患者分成两组 :曲马多组 (T组 )和吗啡组 (M组 )。T组术后注负荷量 10 0mg ,接镇痛泵 ,配方 :0 .12 5 %布比卡因 2 0 0ml加曲马多10 0 0mg ;M组术后注负荷量 1mg ,接镇痛泵 ,配方 :0 .12 5 %布比卡因 2 0 0ml加吗啡 9mg ;两组均采用 48h连续用药加PCA模式。比较术后 48h镇痛效果及不良反应发生率。结果 :( 1)两组患者术后镇痛效果相仿 ,镇痛有效率T组为 90 %、M组为 91.6%。组间比较无显著差异 (P <0 .0 5 )。 ( 2 )两组患者呼吸及循环功能稳定。 ( 3 )不良反应发生率分别为 15 %(T组 )和 5 1.67%(M组 ) ,组间比较P <0 .0 1。结论 :T组PCEA优于M组     

左布比卡因与利多卡因合剂用于肌间沟臂丛神经阻滞临床观察

目的：评价0.375%左布比卡因与1%利多卡因合剂用于成人肌间沟臂丛神经阻滞的麻醉效果,以及对中枢神经系统和心血管系统的影响。方法：选择上肢手术患者40例,并随机分为0.375%左布比卡因与1%利多卡因合剂组（A组,n=20）和0.375%布比卡因与1%利多卡因合剂组（B组,n=20）,行肌间沟臂丛神经阻滞麻醉,均注入局麻药25 ml（含1∶400 000肾上腺素）,观察臂丛神经C5~T1感觉阻滞起效时间、肩关节、肘关节运动阻滞起效时间和臂丛神经阻滞维持时间及镇痛维持时间。结果：两组在C5-T1神经感觉阻滞起效时间和运动阻滞起效时间差异无显著性（P〉0.05）;在臂丛神经阻滞维持时间及镇痛维持时间组间差异也无显著性（P〉0.05）;A组有2例、B组有4例出现心动过缓症状,两组均无毒性反应发生。结论：0.375%左布比卡因与1%利多卡因合剂用于肌间沟臂丛神经阻滞具有起效快,效果优良,安全可靠的优点。     

维拉帕米吗啡在臂丛神经阻滞中的应用

吗啡注入椎管内用于术后镇痛效果确切 ,也有成功用于外周神经镇痛的报道 ［１］;维拉帕米作为钙通道阻滞剂 ,与疼痛调控密切相关 ,具有一定的镇痛和神经传导阻滞作用［２］。本文旨在观察维拉帕米及吗啡注入臂丛神经鞘内对神经阻滞效果及术后镇痛的作用。１临床资料手部及前臂手术病人８０例。男４６例 ,女３４例 ,平均年龄（３６±１２）岁 ,平均体重（５７±１１）ｋｇ,平均手术时间（１２９±１６）ｍｉｎ。术前均不用镇静镇痛药。采用锁骨上入路行臂丛神经阻滞 ,局麻药为１．２%利多卡因及０．１５%丁卡因合剂２５ｍｌ（含１ :２０万 ｕ…     

剖宫产术后吗啡氟哌利多复合硬膜外镇痛的临床观察

目的 :氟哌利多小剂量硬膜外持续注射用于剖宫产术后吗啡镇痛 ,观察其疗效。方法 :随机选择 60例剖宫产患者分为两组 ,关腹时Ⅰ组注入吗啡 0 5mg 生理盐水至 8ml,维持用吗啡 4mg 布比卡因 15 0mg 生理盐水至 10 0ml。Ⅱ组注入吗啡0 5mg 氟哌利多 1 0mg 生理盐水至 8ml,维持用吗啡 4mg 氟哌利多 4mg 生理盐水至 10 0ml ,速度 2ml h。结果 :两组患者镇痛效果达 86 7%～ 93 3 % ,无显著差异 ,术后恶心、呕吐发生率Ⅱ组较Ⅰ组明显减少 (P <0 0 1)有统计学意义 ,其他不良反应无明显减少 ,无一例出现呼吸抑制 ,循环维持稳定。结论 :硬膜外持续小剂量注射吗啡与氟哌利多用于剖宫产术后镇痛是一种安全、有效、不良反应少、费用低、实用的镇痛方法。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.