持续硬膜外镇痛用于防治硬膜穿破后头痛的疗效观察

目的:观察持续硬膜外镇痛(CEA)用于防治硬膜穿破后头痛(PDPH)的疗效。方法:30例意外出现硬膜穿破者随机分为观察组和对照组各15例。观察组采取CEA等方法,对照组则采取硬膜外腔单次注入生理盐水等方法,对2组患者头痛、头晕恶心、呕吐发生情况及不同时间段的相关评分和安全性进行观察。结果:观察组头痛发生率为13.33%、头晕恶心发生率6.67%,呕吐0例,均低于对照组,头痛持续时间较对照组明显缩短(P<0.05);且术后第2、3、4、5天观察组的头痛评分、头晕恶心评分和呕吐评分均低于对照组(P<0.05),2组安全性相比差异无统计学意义(P>0.05)。结论:CEA用于防治PDPH疗效确切。     

安氟醚及异氟醚吸入麻醉对AEPI的影响

目的研究不同的吸入麻醉药在不同的MAC下，手术前、切皮时、手术中AEPI的变化。方法ASA1-2级择期腹部手术患者40例，分为安氟醚组（R）、异氟醚组（Iso），每组20例。诱导后于切皮前顺序吸入0．5MAC、1．0MAC、1．5MAC，切皮时吸入1．0MAC或1．5MAC，切皮后顺序吸入1．5MAC、1．0MAC、0．5MAC达到后平衡10min，术毕停止吸入麻醉药。监测不同MAC时及苏醒时AEPI值。结果组内比较：En组：切皮前吸入0．5MAC时AEPI高于吸入1．0MAC、1．5MAC，P〈0．05。切皮时吸入1．0MAC时AEPI高于1．5MAC，P〈0．05。吸入0．5MAC时，切皮前AEPI值高于切皮后，P〈0．05。组间比较：切皮前吸入0．5MAC En组AEPI值高于Iso组，P〈0．05。结论安氟醚、异氟醚吸入麻醉药浓度为1．0MAC或1．5MAC时AEPI组内与组间比较，无显著性差异，并且此时AEPI值显示患者处于无意识状态。     

安氟醚注入全紧闭吸入麻醉

近年有些学者根据时间平方根计量原则用注射器将挥发性吸入麻药直接注入麻醉循环圈中施行紧闭吸入麻醉，效果满意[1，2]。作者在100例病人中，用微量注射泵将安氟醚连续注入麻醉循环圈中行全紧闭循环吸入麻醉，现报告如下。1资料与方法1．1一般资料：择期手术（ASA）Ⅰ～Ⅱ级病人100例，男65例，女35例，年龄14～71岁，体重36～67kg，计颅内手术21例，开胸（非心脏）手术63例，颌面、颈部手术11例，上腹部手术5例。1．2仪器：用Ohio麻醉机、Cortroller－Ⅱ呼吸器，微量注射泵、MEC－9010麻酸气体监测仪。1．3麻醉方法：全部病例均于术前…     

七氟醚和异氟醚麻醉吸入术后苏醒效果的临床分析

选择在我院就诊的接受手术治疗的患者86例,随机分为对照组和观察组各43例。采用异氟醚对对照组患者在术中实施吸入麻醉;采用七氟醚对观察组患者在术中实施吸入麻醉。结果观察组患者术后睁眼时间、PACU留置时间、术后拔除气管导管时间明显短于对照组;术后躁动等现象的发生率明显低于对照组;手术前后MMSE评分的变化幅度明显小于对照组;手术麻醉效果明显优于对照组。应用七氟醚对接受手术治疗的患者实施吸入麻醉的效果较异氟醚更加理想。     

异氟醚吸入用于心脏手术麻醉的临床观察

异氟醚(ISO)具有理化和生物性质稳定、麻醉诱导快、苏醒早、无肝肾毒性、对循环功能影响较小等特点。但因动物实验表明ISO有“心肌窃血”作用,而在临床心脏手术病人中应用存在争议,本文旨在     

异氟醚和安氟醚对海马神经元作用机制的研究

目的：观察异氟醚和安氟醚吸入麻醉时海马神经元对一氧化氮合酶、脑啡呔和自发放电的影响，为综合评价海马在产生全身麻醉效应过程中的作用提供依据。方法：采用免疫组织化学双重标记法和膜片钳技术。结果：安氟醚和异氟醚能明显引起海马CA1区c-fos基因阳性神经元(FPN)和脑啡呔阳性神经元(EPN)表达明显高于对照组(P&;lt;0．01)，并有一定数量FPN／NPN双标阳性神经元(P&;lt;0．01)，还能明显抑制一氧化氮阳性神经元(NPN)的表达(P&;lt;0．01)。同时安氟醚和异氟醚都能含量依赖性的抑制海马CA1区神经元自发放电频率。与给药前比较P&;lt;0．05或P&;lt;0．01。     

硬膜穿刺后头痛预防的最佳证据总结

[目的]全面检索、评价和总结硬膜穿刺后头痛预防的最佳证据,为构建相关评估工具提供参考。[方法]通过计算机检索NGC、BMJ最佳临床实践,uptodate,JBI、Cochrane library,pubMed、embase、中国生物医学文献数据库(CBM)等数据库中关于硬膜穿刺术后头痛预防的所有证据。严格按照纳入、排除标准筛查文献进行文献质量评价,并提取证据,对证据级别进行评定。[结果]共纳入14篇文献,其中指南3篇,实践指南1篇,临床决策1篇,系统评价9篇。最终提取出15条最佳证据,涉及针头选择、进针角度、拔针技巧、体位管理、补液用药等方面。[结论]医护人员应以循证的观点指导实践,降低病人硬膜穿刺后头痛发生率,减轻病人的痛苦。部分证据还需要进一步高质量多中心的研究,以增强其可信性,达到效果最大化。     

产妇硬脊膜穿刺后头痛的循证防治

目的探讨产妇硬脊膜穿刺后头痛(PDPH)的循证预防治疗措施。方法计算机检索Cochrane图书馆(2006年第3期)、MEDLINE(1980.1～2006.10)和中国生物医学文献数据库(1980.1～2006.10),收集关于产妇硬脊膜穿刺后头痛防治的系统评价、Meta分析和临床对照试验(RCT),并评价所获得的证据质量。结果共检索到2篇Cochrane系统评价,2篇Meta分析和9篇RCT。分析结果表明,硬膜外自体血液填充治疗疗效确切,体位、液体和药物治疗对产妇PDPH的发生率和严重性无明显影响。选择适当腰麻穿针刺和穿刺技术能有效降低产妇PDPH的发生,而蛛网膜下腔注入生理盐水和置管预防技术的价值尚有待进一步验证。结论硬膜外自体血液填充对产妇的PDPH具有确切的治疗作用,选择适当腰麻穿刺针和穿刺技术能有效预防产妇PDPH的发生。     

不同体位对腰穿后头痛的影响

目的 评价不同体位对腰穿后头痛的影响,为临床选择最佳腰穿后体位提供依据。方法 用随机单盲法将符合条件的164例患者分成4组:A组(去枕平卧6h)、B组(平行位头抬高5cm平卧6h)、C组(头低脚高俯卧1h,左右交替侧卧或平卧5h)、D组(头低脚高俯卧1h,左右交替侧卧或平卧2h),观察其在腰穿术后6、24、48、72h头痛发生率、头痛程度、头痛持续时间及不适指标。结果 4组体位头痛发生率分别是23.80％、22.50％、27.50％、19.05％,头痛发生率、头痛程度、持续时间无显著差异(P>0.05);B组舒适率显著低于其他3组(P<0.05)。结论 D组体位为最佳腰穿后体位。     

Correlation of Adverse Neurological Outcomes with Increasing Volumes and Delayed Administration of Autologous Epidural Blood Patches for Postdural Puncture Headaches

Introduction: Epidural blood patches (EBPs) usually afford rapid and successful treatment outcomes for postdural puncture headaches (PDPH) with few adverse sequelae. Patients and Methods: In order to identify potential risk factors for any adverse outcomes of EBP, a Medline search, 1966 to the present, of case reports and series of any adverse outcomes following EBP for PDPH was conducted. The literature search identified 26 patient cases with 21 cases defined as adverse neurological outcomes, and further stratified as compression or noncompression syndromes, and five cases defined as persistent cranial nerve (CN) palsies. Cases were also stratified by age, sex, and blood volumes of EBP or delays in administration, and compared for statistically significant differences in continuous variables by unpaired, two‐tailed t‐tests and for significant correlations between predictor variables, including EBP volumes and delays in administration, and adverse neurological outcomes, by simple linear regression analysis. Results: There were no statistically significant sex differences in the mean ages or weights of the study population, or in the total volumes of autologous blood injected in EBPs. When the study population was compared for adverse neurological outcomes by compression or noncompression syndromes, patients experiencing compression syndromes received significantly more EBP volumes (35.36 mL) than patients experiencing noncompression (17.46 mL) syndromes (P = 0.025). Regression analysis confirmed a significant direct linear relationship between increasing EBP volumes and worsening adverse neurological outcomes (P = 0.008). In patients with CN palsies associated with PDPH and unrelieved by EBP, regression analysis again confirmed significant direct linear relationships between increasing days waited to perform EBP and increasing duration of CN palsies in months (P = 0.001). Conclusions: Epidural blood patches for the management of PDPH, especially PDPH associated with CN palsies, should be administered as soon as the diagnosis of PDPH is made with lower volumes of autologous blood (≤20 mL) to assure the best treatment outcomes.     

Bilateral Subdural Hematoma after Inadvertent Dural Puncture during Epidural Analgesia

Background

Post-dural puncture headache (PDPH) is typically a benign complication of dural puncture that is clinically diagnosed. It commonly presents as a throbbing and positional headache that occurs 24-48 h after dural puncture. Subdural hematomas, if unrecognized, may occur as a rare and life-threatening complication of dural puncture.

Objectives

We aim to describe the clinical features and sequelae of a rare complication that may result as a consequence of inadvertent dural puncture that, if unrecognized, has the potential to become a life-threatening complication from a common procedure.

Case Report

We report the case of a previously healthy 17-year-old primigravida female who initially presented 4 days postpartum with clinical features and imaging studies consistent with PDPH. The patient's symptoms were unremitting, and within 4 weeks, she developed bilateral subdural hematoma. With prompt recognition and diagnosis, she was treated with conservative medical management and subsequently improved on follow-up.

Conclusion

Patients with unremitting PDPH should prompt the clinician to suspect the development of subdural hematoma as a potential life-threatening complication of an otherwise benign condition.     

Persistent Post-DuraI-Puncture Headache Treated With Epidural Infusion of Dextran

SYNOPSIS
A retrospective review was done on medical records of 13 patients with persistent post-dural-puncture headaches after one or more epidural blood patches. Headache occurred in nine patients with post-laminectomy syndrome after "wet taps" while performing epidural blocks. In two patients post-dural-puncture headache appeared after long term implanted intrathecal catheters were removed. In two other cases headache developed after spinal anesthesia. Treatment included bed rest, intravenous hydration and at least one epidural blood patch; three patients were given 60 milliliters of epidural saline, without success. Eight epidural catheters were inserted through the lumbar access and five through the caudal approach. Initially, a bolus of 20 milliliters of dextran-40 was given followed by an infusion of 3 mL/hr, until 12 hours after the head pain and any other related symptoms subsided. In all patients the headache disappeared within 20 hours after initiating therapy (9.55 mean hours, SD ± 0.79). In five patients headache ceased in less than five hours. Nausea and photo-phobia subsided earlier. Patients with post-dural-puncture headache resistant to other treatments, including at least one epidural blood patch, were successfully treated by a bolus followed by continuous epidural infusion of dextran-40.     

硬脊膜穿通后头痛的诱发因素及防治

硬脊膜穿通后头痛(postduralpunctureheadache,PDPH)不仅增加了病人痛苦,而且常伴发视力障碍、颅神经麻痹等。本文仅就PDPH的诱发因素及相关治疗护理问题进行综述。     

Post‐Dural Puncture Headache: Part II – Prevention,Management, and Prognosis

Post‐dural puncture headache (PDPH) is a frequent complication of lumbar puncture, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. As PDPH can be disabling, clinicians who perform these procedures should be familiar with strategies for preventing this disorder. Since the best preventative measures sometimes fail, clinicians should also be familiar with the therapeutic approaches for PDPH. Herein, we review the procedure‐related risk factors for PDPH, the prognosis of PDPH and the studies of PDPH treatment. We divide the therapeutic approach to PDPH into 4 stages: conservative management, aggressive medical management, conventional invasive treatments, and the very rarely employed less conventional invasive treatments and provide management algorithm to facilitate treatment.     

静脉输液逆向穿刺的临床观察

目的 研究手背远端指掌关节附近静脉输液逆向穿刺的临床效果。方法 采用自身前后对照的方法，对200例患者指掌关节附近血管先后采用逆向、顺向静脉穿刺方法，观察2种方法1次穿刺成功率、穿刺疼痛率、固定后返修率及重新穿刺率。结果 2组患者1次穿刺成功率有差异（P〈0．05）；穿刺疼痛率、固定后返修率、重新穿刺率有显著差异（P〈0．01）。结论 逆向静脉穿刺穿刺成功率高；穿刺疼痛程度轻；返修率和重新穿刺率低，值得临床推广采用。