Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery

IntroductionSpinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost.MethodsThe authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality.ResultsA total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225).Discussion/conclusionTo our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.     

Laparoscopic surgery using spinal anesthesia.

BACKGROUND: Laparoscopic abdominal surgery is conventionally done under general anesthesia. Spinal anesthesia is usually preferred in patients where general anesthesia is contraindicated. We present our experience using spinal anesthesia as the first choice for laparoscopic surgery for over 11 years with the contention that it is a good alterative to anesthesia. METHODS: Spinal anesthesia was used in 4645 patients over the last 11 years. Laparoscopic cholecystectomy was performed in 2992, and the remaining patients underwent other laparoscopic surgeries. There was no modification in the technique, and the intraabdominal pressure was kept at 8mm Hg to 10mm Hg. Sedation was given if required, and conversion to general anesthesia was done in patients not responding to sedation or with failure of spinal anesthesia. Results were compared with those of 421 patients undergoing laparoscopic surgery while under general anesthesia. RESULTS: Twenty-four (0.01%) patients required conversion to general anesthesia. Hypotension requiring support was recorded in 846 (18.21%) patients, and 571(12.29%) experienced neck or shoulder pain, or both. Postoperatively, 2.09% (97) of patients had vomiting compared to 29.22% (123 patients) of patients who were administered general anesthesia. Injectable diclofenac was required in 35.59% (1672) for abdominal pain within 2 hours postoperatively, and oral analgesic was required in 2936 (63.21%) patients within the first 24 hours. However, 90.02% of patients operated on while under general anesthesia required injectable analgesics in the immediate postoperative period. Postural headache persisting for an average of 2.6 days was seen in 255 (5.4%) patients postoperatively. Average time to discharge was 2.3 days. Karnofsky Performance Status Scale showed a 98.6% satisfaction level in patients. CONCLUSIONS: Laparoscopic surgery done with the patient under spinal anesthesia has several advantages over laparoscopic surgery done with the patient under general anesthesia.     

Cerebrospinal fluid free amino acids in patients with spinal space—Occupying lesions

Summary 18 different free amino acids were determined in the cerebrospinal fluid of 28 patients with various spinal space—occupying lesions. The study group included 15 patients with lumbar disc lesions (control group), 8 patients with cervical radiculopathy, 4 patients with cervical myelopathy, and 1 patient with a thoracic spinal angioma.The values from the control group were in general accord with those previously observed in normal adults of 5 studies of the literature. Comparison of the values in the different subgroups showed normal values of all amino acids in patients with cervical myelopathy, and significantly higher levels of glutamic acid in patients with cervical radiculopathy. In the case of a thoracic spinal angioma however most free amino acids were extremely high.The authors conclude that this may be due to alterations of the spinal metabolism and that determination of free amino acids in CSF of patients with intradural spinal lesions may help to improve preoperative diagnosis in addition to neuroradiological methods.     

Laryngo-tracheal laser surgery and general anesthesia

The use of the carbon dioxide laser in treatment of laryngo-tracheal lesions is extremely effective when combined with general anesthesia. However, the potential for intraoperative complication is increased due to a pathological reduction in the size of the airway and the presence of an endotracheal tube. To avoid the hazard of endotracheal tube ignition, specific techniques are employed.     

麻醉护士在快速康复外科模式下急性疼痛服务中的作用

目的探讨麻醉护士在快速康复外科(ERAS)模式下急性疼痛服务(APS)中的作用。方法根据入院时间将患者分为两组,2016年3~9月收治的80例胃肠手术患者(对照组)按照ERAS模式及APS进行围手术期管理,2016年10月至2017年3月收治的73例患者(观察组)在对照组管理基础上增设麻醉护士岗位并使其参与术后疼痛管理,包括APS小组构建、患者疼痛管理档案的建立及APS活动沟通平台的运行。结果两组术后各时间点VAS疼痛评分及术后首次下床时间、首次排气时间、多模式镇痛及自控镇痛率比较,差异有统计学意义(P<0.05,P<0.01)。结论麻醉护士在ERAS模式下APS中有重要作用,有利于麻醉护士专科化发展。     

Recovery of dynamic balance after general anesthesia with sevoflurane in short-duration oral surgery

Purpose  Recovery of dynamic balance, involving adjustment of the center of gravity, is essential for safe discharge on foot after ambulatory anesthesia. The purpose of this study was to assess the recovery of dynamic balance after general anesthesia with sevoflurane, using two computerized dynamic posturographies. Methods  Nine hospitalized patients undergoing oral surgery of less than 2 h duration under general anesthesia (air-oxygensevoflurane) were studied. A dynamic balance test, assessing the ability of postural control against unpredictable perturbation stimuli (Stability System; Biodex Medical), a walking analysis test using sheets with foot pressure sensors (Walk Way-MG1000; Anima), and two simple psychomotor function tests were performed before anesthesia (baseline), and 150 and 210 min after the emergence from anesthesia. Results  Only the double-stance phase in the walking analysis test showed a significant difference between baseline and results at 150 min. None of the other variables showed any differences among results at baseline and at 150 and 210 min. Conclusion  The recovery times for dynamic balance and psychomotor function seem to be within 150 min after emergence from general anesthesia with sevoflurane in patients undergoing oral surgery of less than 2-h duration.     

右美托咪定对全麻下髋关节置换术术后认知功能的影响

目的：探讨右美托咪定对全身麻醉下髋关节置换术术后老年患者认知功能的影响,为全身麻醉下髋关节置换术辅助用药的选择提供依据。方法选择于我院择期行髋关节置换手术的老年患者72例,分为观察组和对照组,每组36例。观察组在术前给予右美托咪定辅助全身麻醉患者的镇静,然后两组皆给予全身麻醉下髋关节置换术和相应常规处理,并通过简易精神状态量表（mini-mental state examination,MMSE）评估患者认知功能的改变以及认知功能障碍的发生率。结果观察组与对照组患者在体液量、手术时间、麻醉时间等方面无显著统计学差异（P＞0.05）。在术后S100蛋白含量方面差异有统计学意义（P＜0.05）。在术后第1天、第7天的MMSE评分存在统计学差异。术后第3天,对照组认识功能障碍的发生率为27.78%（10/36）,观察组认识功能障碍的发生率为19.45%（7/36）,两组间存在统计学差异（P＜0.05）。术后第9天,两组患者认知能力均有部分恢复,对照组发生率为16.67%（6/36）,观察组发生率为8.3%（3/36）,两组间存在统计学差异（P＜0.05）。结论研究发现右美托咪定具有明显的镇静作用,能够帮助改善老年患者全身麻醉下髋关节置换术后的认知功能障碍。     

脊柱手术后脑脊液漏的中西医结合治疗

目的 探讨脊柱外科手术后常见并发症脑脊液漏的中西医结合治疗方法及效果。方法 对脊柱手术后脑脊液漏的16例患者进行分析总结。结果 经过术中处理及术后中西医结合治疗。16例经保守治疗后于4～15d内脑脊液漏停止，切口一期愈合。术后随访9～28个月，未发现脑脊液漏，患者未遗留腰背痛及头晕头痛等症状。结论 通过术中积极修补破裂硬脊膜或压迫填塞处理，术后采用中西医结合方法治疗，脑脊液漏均可治愈，特别是中药的运用对于减少脑脊液渗出，预防、减轻、消除并发症有积极意义。     

缩短全麻下咽喉部手术患儿术后禁食禁饮时间研究

目的探讨咽喉部患儿全身麻醉术后适宜的禁食时间,促进患儿术后恢复。方法将102例择期咽喉部全麻手术患儿(3～14岁)随机分为观察组(53例)和对照组(49例)。观察组在患儿意识清醒且吞咽功能恢复的前提下2h后开始进食,先饮少量凉开水,如无误吸现象可进纯奶油冰淇淋或流质;对照组按照常规护理,即患儿麻醉清醒6h后开始进食。比较两组患儿术后6h、24h疼痛、恶心、呕吐、口渴、饥饿等不适发生率。结果观察组患儿术后6h疼痛、恶心、口渴、饥饿不适症状发生率显著低于对照组(均P<0.01)。结论早期进食能有效缓解咽喉部患儿全麻术后的不适症状,有利于患儿尽快恢复。     

全凭静脉麻醉与静-吸复合麻醉下腰椎手术中神经电生理监测的比较

目的比较全凭静脉麻醉与静-吸复合麻醉在腰椎手术中对体感诱发电位(SSEP)及运动诱发电位(MEP)的影响。方法选择择期行全麻腰椎手术患者60例,随机均分为两组,每组30例。麻醉维持时T组丙泊酚TCI血浆靶浓度为3.0~3.5μg/ml,I组吸入1%七氟醚复合丙泊酚泵注,两组均维持BIS在40~50。记录清醒时(T0)、插管后5 min(T1)、切皮时(T2)以及椎管减压时(T3)的SSEP和MEP等相关参数,并记录运动诱发电位未引出情况。结果与T0时比较,T1~T3时两组P38、N45波潜伏期明显延长(P0.05),波幅明显降低(P0.05),但组间差异无统计学意义。两组无一例出现术中单侧或双侧下肢的MEP消失。结论与单纯丙泊酚全凭静脉麻醉比较,复合1%七氟醚麻醉并不影响腰椎手术中SSEP及MEP的监测,可用于行神经电生理监测的脊柱手术。     

氯普鲁卡因、布比卡因和罗哌卡因在下肢手术腰-硬联合麻醉中的比较

目的比较氯普鲁卡因、布比卡因和罗哌卡因在下肢手术腰-硬联合麻醉(CSEA)中的应用效果。方法择期行髋关节及以下部位手术患者300例,随机均分成三组:氯普鲁卡因组(C组)、布比卡因组(B组)和罗哌卡因组(R组),蛛网膜下腔分别给予1.5%氯普鲁卡因、0.5%布比卡因和0.5%罗哌卡因各2 ml。记录患者感觉阻滞起效时间、平面固定时间、阻滞平面、腰麻持续时间和运动阻滞效果。结果 C组阻滞平面固定时间、腰麻持续时间明显短于B、R组(P<0.05)。C组感觉阻滞起效时间短于B组,但长于R组(P<0.05)。C组最高阻滞平面明显高于B、R组(P<0.05)。结论与0.5%罗哌卡因和0.5%布比卡因比较,1.5%氯普鲁卡因具有起效快、阻滞完善和运动阻滞效果弱的特点,小剂量氯普鲁卡因可用于手术时间较短的CSEA中的脊麻。     

微泵输注持续腰麻在妇科盆腔肿瘤手术中的应用

目的研究微量输注泵(微泵)输注持续腰麻在妇科盆腔肿瘤手术中的应用。方法择期行妇科盆腔肿瘤根治手术患者60例,随机均分为持续注药腰麻组(Ⅰ组)和间断注药腰麻组(Ⅱ组)。Spinocath导管针行蛛网膜下隙穿刺置管后予0·5%重比重布比卡因行麻醉诱导,至阻滞平面达T4~T6。平面固定后,Ⅰ组用微泵注入0·375%等比重布比卡因2ml/h维持麻醉;Ⅱ组依手术情况及患者反应间断追加0·75%等比重布比卡因每次1ml。监测并记录相应时点ECG、MAP、HR及SpO2,记录局麻药用量和不良反应。结果两组麻醉效果满意。Ⅰ组麻醉维持局麻药用量少于Ⅱ组(P<0·05)。诱导后两组MAP缓慢下降,20min时较麻醉前明显下降(P<0·05),但60min和90min时Ⅱ组显著高于Ⅰ组(P<0·05)。结论微泵输注持续腰麻能得到满意的麻醉效果。     

多感官干预对全麻斜视矫正术患儿的影响

目的 探讨多感官干预模式对于全麻斜视矫正患儿苏醒期躁动的影响。 方法 将全麻下行斜视矫正术患儿70例,随机分为对照组和干预组各35例。对照组实施苏醒期常规护理,干预组在常规护理基础上实施多感官干预模式。比较两组苏醒期躁动发生率,疼痛,苏醒期不良反应,苏醒室留观时长,脑电双频指数值＞60、70、80所需时长。 结果 干预组苏醒期躁动发生率、术后疼痛程度、苏醒期敷料挣脱发生率显著低于对照组,干预组脑电双频指数＞80所需时长、苏醒室留观时长显著短于对照组（均P＜0.05）。 结论 多感官干预作为一种全方位、简便易操作的干预模式,能降低全麻患儿苏醒期躁动发生率、减轻术后疼痛、减少苏醒期不良反应发生,提高苏醒护理质量。     

全身麻醉整形外科手术后反复发作性摇头一例

1例49岁乳房萎缩、腹部脂肪堆积患者,于2018年1月29日就诊于中国医学科学院整形外科医院。在全身麻醉下行腹部脂肪抽吸和乳房脂肪填充术后无明显诱因出现反复发作性摇头,发作时头部快速左右旋转约90°,每次持续3~10 s,不伴随面部和四肢抽动。患者神志清楚,生命体征平稳,主诉无法自控摇头。给予镇静及镇痛药后无明显改善,后予心理支持治疗,未经其他处理,患者于发病后3 h症状终止。排除全身麻醉术后躁动、既往精神类疾病和相关用药史后,考虑诱发因素可能为癫痫发作和癔症。该病例术后发生反复性摇头的病因、发病机制、诊治方面仍有待进一步商榷,但提示医护人员在处理临床问题时应进行全面分析,不仅要重视和诊断患者的器质性病变,同时也要关注患者心理和精神因素的影响,为采取适宜的药物和心理治疗提供依据,以期达到最佳治疗效果。     

The effect of combined epidural and light general anesthesia on stress hormones in open heart surgery patients

P < 0.05) just before skin closure, on the second and the third postoperative day. The β-endorphin levels were substantially lower in group EAA than in group GA throughout the observation. The pain scores were good in 2 patients (17%), fair in 6 (50%), and poor in 4 (33%) for group GA, and good in 8 (67%), fair in 3 (25%), and poor in 1 (8%) for group EAA. We thus conclude that a combined epidural and light general anesthesia is considered to attenuate the stress response and thereby provides a better quality of postoperative pain control. (Received for publication on Nov. 27, 1996; accepted on July 8, 1997)     

Comparison between intra-articular bupivacaine with epinephrine and epinephrine alone on short-term and long-term pain after knee arthroscopic surgery under general anesthesia in day-surgery patients

BACKGROUND: : Postarthroscopy analgesia has been provided with intra-articular bupivacaine, but reported results are conflicting regarding efficacy and the duration of analgesia. The immediate and long-term effects of intra-articular bupivacaine with epinephrine after arthroscopic knee surgery were therefore studied in a day surgery setting. METHODS: : 120 ASA I-II patients scheduled for arthroscopic knee surgery were given general anesthesia with spontaneous breathing via a laryngeal mask. In a randomized and blinded fashion half of them received, at the end of surgery, intra-articularly 20 mL 0.5% bupivacaine with epinephrine (B + E-group) and the other half 20 mL saline with epinephrine (S + E-group). All patients received ketoprofen 100 mg i.v. during surgery and another 100 mg 2-3 h postoperatively. The patients were observed for about 4.5 h in the day surgery unit before discharge. RESULTS: : The results showed that in comparison with the S + E-group, significantly fewer patients in the B + E-group needed analgesics (P < 0.0001) and the amount required was also significantly less postoperatively, before discharge (about 4.5 h postoperatively) (P < 0.0001). The latency to the need for the first postoperative analgesic was shorter in the S + E-group patients (P < 0.0001). At home, during seven days after discharge, the need for analgesic (oral ketoprofen 100 mg) was greater in the B + E-group (P < 0.05), especially only during the second postoperative day, but the visual analoque pain scale (VAPS) scores were low with no differences between the groups. No complication occurred. CONCLUSION: : It is concluded that a good postoperative pain control of intra-articular bupivacaine with epinephrine was found only in the immediate postoperative period (i.e. before discharge) in a day-surgery arthroscopic knee surgery patients.     

Levels of preoperative cerebrospinal fluid pro-inflammatory mediators and chronic pain after total knee arthroplasty surgery

Background

Patients undergoing total knee arthroplasty (TKA) surgery are at high risk of chronic postsurgical pain (CPSP). Accumulating evidence suggests an active role of neuroinflammation in chronic pain. However, its role in the progression to CPSP following TKA surgery remains unanswered. Here, we examined the associations between preoperative neuroinflammatory states and pre- and postsurgical chronic pain in TKA surgery.

Methods

The data of 42 patients undergoing elective TKA surgery for chronic knee arthralgia at our hospital were analyzed in this prospective study. Patients completed the following questionnaires: brief pain inventory (BPI), hospital anxiety and depression scale, painDETECT, and pain catastrophizing scale (PCS). Cerebrospinal fluid (CSF) samples were collected preoperatively and concentrations of IL-6, IL-8, TNF, fractalkine, and CSF-1 were measured by electrochemiluminescence multiplex immunoassay. CPSP severity was ascertained, using the BPI, 6 months postsurgery.

Results

While no significant correlation was observed between the preoperative CSF mediator levels and preoperative pain profiles, the preoperative fractalkine level in the CSF showed a significant correlation with CPSP severity (Spearman's rho = −0.525; p = .002). Furthermore, multivariate linear regression analysis revealed that the preoperative PCS score (standardized β coefficient [β]: .11; 95% confidence interval [CI]: 0.06–0.16; p < .001) and CSF fractalkine level (β: −.62; 95% CI: −1.10 to −0.15; p = .012) were independent predictors of CPSP severity 6 months after TKA surgery.

Conclusions

We identified the CSF fractalkine level as a potential predictor for CPSP severity following TKA surgery. In addition, our study provided novel insights into the potential role of neuroinflammatory mediators in the pathogenesis of CPSP.     

氯普鲁卡因腰麻或腰-硬联合麻醉的临床研究

目的 探讨国产氯普鲁卡因用于腰麻或腰一硬联合麻醉的效果和安全性.方法 回顾性分析10 000例下腹部以下手术患者采用国产氯普鲁卡因冻干粉(生理盐水稀释成2.5%或3%溶液)腰麻或腰-硬联合麻醉.结果 腰麻平均起效时间24 s,平面固定时间7.7 min.最高阻滞平面平均为T_5.下肢运动阻滞3级者超过94%.腰麻效果平均满意率99.8%,硬膜外辅助麻醉后满意率提高到99.9%.单次腰麻完全消失平均72 min.产科患者腰麻后低血压和恶性呕吐发生率较高(分别为34%和43%).未见明显神经系统并发症和其他不良反应.结论 国产氯普鲁卡因冻干粉溶解后用于腰麻或腰一硬联合麻醉安全、有效.