Patient controlled epidural analgesia: interest in thoracic surgery

AIM: To compare efficacy of pain control, the consumption of local anaesthetics and opioids as well as the side effects between continuous epidural analgesia, patient controlled analgesia and patient controlled epidural analgesia in thoracic surgery. METHODS: Prospective randomised study included 66 patients who had thoracotomy. Patients were divided into 3 groups, to receive different pain control methods. Group 1 (n=22) received patient control analgesia Group 2 (n=22) received continuous epidural analgesia (Bupivacaine 0,125% + 5 microg/ml of Fentanyl) between 6 and 10 ml/h in order to obtain a T2 level Group 3 (n=22) received patient controlled epidural analgesia (Bupivacaine 0,08% + 3 microg/ml of Fentanyl) 6 ml/h and bolus of 5 ml. RESULTS: There was no difference between the three groups in age, delay of surgical operation and per operative morphine consumption. VAS was less at rest and after cough in patient group with patient controlled epidural analgesia. The difference was less significant in local anaesthetics and opioids consumption in patient with controlled epidural analgesia. CONCLUSION: The benefit of patient controlled epidural analgesia in thoracic surgery is proven by the following analgesic efficiency which allows good respiratory rehabilitation, decreasing the risk of drug toxicity by decreases consumption, weak hemodynamic effects and absence of motor block.     

加巴喷丁对乳腺癌术后患者自控静脉镇痛的影响

目的 评价乳腺癌改良根治术患者围手术期单次剂量加巴喷丁对术后丁丙诺啡患者自控静脉镇痛的影响.方法 择期全麻下行乳腺癌改良根治术的女性患者60例,ASA分级Ⅰ～Ⅱ级,根据计算机随机数字表法分为加巴喷丁组和安慰剂组,每组30例,分别在麻醉诱导前口服加巴喷丁1200mg或匹配的安慰剂.患者均接受丁丙诺啡患者自控静脉镇痛,共53例完成本研究,安慰剂组28例,加巴喷丁组25例.观察两组术后静息和动态视觉模拟评分(VAS)、术后恶心呕吐(PONV)分级、焦虑程度评分、Ramsay镇静评分、镇痛泵丁丙诺啡用量、第一次患者自控性镇痛时间等.结果 加巴喷丁组术后各时间点静息、动态VAS低于安慰剂组(P＜0.05).加巴喷丁组镇痛泵丁丙诺啡用量(506.1±37.9)μg、第一次患者自控性镇痛时间(21.1±2.3)min、PONV发生率为40.0%(10/25)、需追加镇吐药率为12.0%(3/25)、焦虑程度评分(28.5±12.1)分,安慰剂组分别为(699.8±87.8)μg、(4.3±0.8)min、64.3%(18/28)、32.1%(9/28)和(66.3±15.7)分,两组比较差异均有统计学意义(P＜0.05).结论 乳腺癌改良根治术患者口服单次剂量的加巴喷丁1200mg能有效缓解术后疼痛、减少丁丙诺啡用量、降低PONV的发生、缓解焦虑.     

集束化护理在癌痛规范化治疗中的应用研究

目的：探讨集束化护理在癌痛规范化治疗中对癌痛患者疼痛强度和疼痛影响是否有明显的缓解。方法：将本科2013年6月-2014年3月收治的80例病理确诊为恶性肿瘤,存在癌性疼痛,并接受三级阶梯止痛药物镇痛治疗的患者随机分成对照组和试验组,每组40例。对照组按照规范的三级阶梯止痛原则进行护理,试验组采用集束化护理措施,包括：评估癌痛→实施镇痛→健康教育→观察与记录→定期随访。观察两组癌痛患者干预前后疼痛强度、疼痛影响及止痛药的不良反应。结果：护理干预后,两组在疼痛强度与疼痛影响方面评分均明显下降（P〈0.01）,试验组下降程度较对照组更明显（P〈0.01）;试验组癌痛缓解率明显高于对照组（P〈0.01）,且药物不良反应较低（P〈0.05）。结论：集束化护理措施能明显降低癌痛患者的疼痛程度和疼痛对生活质量的影响,值得推广应用。     

全膝关节置换术患者术后股神经阻滞和收肌管阻滞的比较

目的 研究股神经阻滞和收肌管阻滞对TKA患者术后镇痛作用及对运动的影响。方法 选取本院关节外科需进行全膝关节置换的50例患者为研究对象,将其随机分为实验组和对照组,实验组进行收肌管阻滞镇痛,对照组进行股神经阻滞镇痛。观察2组患者术前、术后(2 h、6 h、12 h、24 h、48 h)疼痛评分,术前、术后股四头肌肌力和关节活动度并进行比较。结果 2组患者术前静息痛、活动痛的VAS评分无明显差异(P＞0.05),术后2 h、6 h、12 h、24 h、4 8h,2组患者的静息痛、活动痛的VAS评分差异无统计学意义(P＞0.05)。收肌管阻滞组患者术后24 h、48 h股四头肌肌力明显优于股神经阻滞组,差异有统计学意义(P＜0.05);术后72 h,2组患者股四头肌肌力差异无统计学意义(P＞0.05);收肌管阻滞组患者在术后各时点上膝关节活动度明显大于股神经阻滞组患者,差异有统计学意义(P＜0.05)。结论 股神经阻滞和收肌管阻滞对TKA患者术后的镇痛作用差异无统计学意义,但是对收肌管阻滞组患者股四头肌肌力和关节活动度恢复较股神经阻滞快,有利于患者早期进行功能锻炼和及早恢复。     

不同镇痛方法用于乳腺癌手术病人术后镇痛的疗效观察

目的将病人自控静脉镇痛(PCIA)和自控硬膜外镇痛(PCEA)分别用于乳腺癌手术病人术后镇痛,观察镇痛效果及不良反应情况。方法 60例ASAI～II级择期行乳腺癌手术病人,随机分为A组和B组,每组30例。A组在全麻诱导气管插管后及手术结束时各静注氟比洛芬酯50mg,并联合芬太尼开始PCIA,B组术后采用吗啡行PCEA,记录两组病人术后4、8、12、24、48h疼痛视觉模拟评分(VAS)及不良反应情况。结果两组病人术后各时点VAS差异无统计学意义;A组病人术后恶心呕吐、皮肤瘙痒、尿潴留等不良反应的发生率明显低于B组(P<0.05)。结论氟比洛芬酯术前超前镇痛并联合芬太尼行PCIA可以产生理想的镇痛效果,同时减少阿片类药物不良反应。     

不同镇痛方法用于乳腺癌手术病人术后镇痛的疗效观察

目的将病人自控静脉镇痛（PCIA）和自控硬膜外镇痛（PCEA）分别用于乳腺癌手术病人术后镇痛．观察镇痛效果．gear良反应情况。方法60例ASAⅠ～Ⅱ级择期行乳腺癌手术病人,随机分为A组和B组,每组30例。A组在全麻诱导气管插管后及手术结束时各静注氟比洛芬酯50mg,并联合芬太尼开始PCIA,B组术后采用吗啡行PCEA,记录两组病人术后4、8、12、24、48h疼痛视觉模拟评分（VAS）及不良反应情况。结果两组病人术后各时点VAS差异无统计学意义：A组病人术后恶心呕吐、皮肤瘙痒、尿潴留等不良反应的发生率明显低于B组（P〈0．05）。结论氟比洛芬酯术前超前镇痛并联合芬太尼行PCIA可以产生理想的镇痛效果,同时减少阿片类药物不良反应。     

地佐辛超前镇痛对老年患者术后认知功能的影响分析

目的：探察地佐辛镇痛剂在老年手术患者超前镇痛应用时,对术后认知功能的影响。方法：选取接受择期髋关节置换手术治疗的180例老年患者,随机分为对照组和试验组,每组90例。试验组患者于麻醉前注射5 mg地佐辛;对照组注射等量的生理盐水注射液,随后对所有患者进行全身性的麻醉。在手术前后不同时段分别为两组患者做简易智力状态检查（MMSE）测试、血浆皮质醇浓度检测以及术后认知功能障碍（POCD）的总体发生比率。结果：与对照组相比试验组患者MMSE术前、术后得分均较高,且血浆皮质醇的浓度有所降低;POCD发生比例占19%,比对照组的32%稍低。结论：地佐辛在老年手术患者超前镇痛方面的应用具有一定的积极效果,可减轻患者手术疼痛,降低老年术后认知功能障碍发生的风险。     

肋间神经冷冻和硬膜外自控镇痛在胸外科术后镇痛中的比较

目的 比较肋间神经冷冻和硬膜外自控镇痛在胸外科术后镇痛中的临床效果.方法 将2006年4月至2008年5月开胸手术治疗的89例患者按照随机数字表法随机分为肋间神经冷冻组(A组,47例)和硬膜外自控镇痛组(B组,42例).比较两种方法在术后疼痛程度评分、术后止痛药物应用次数、术后下床活动时间上的差异.结果 A组患者术后疼痛程度评分为(1.49±0.80)分,B组为(2.43±1.21)分,两组比较差异有统计学意义(P<0.05). A组和B组术后止痛药物应用次数[(1.28±0.62)、(2.02±1.05)次]、术后下床活动时间[(43.15±12.22)、(64.10±14.25)h]比较差异均有统计学意义(P<0.05).结论 肋间神经冷冻在治疗效果上优于硬膜外自控镇痛,肋间神经冷冻在胸外科术后镇痛中可以提供满意的镇痛效果.     

不同麻醉和镇痛方法对老年患者非心脏手术术后早期认知功能的影响

目的：探究不同麻醉和镇痛方法对老年患者非心脏手术术后早期认知功能的影响,为临床提供参考。方法：选取2012年6月-2013年12月来本院接受非心脏手术治疗的240例老年患者,按照随机数字表法将其分为全身麻醉静脉镇痛组和腰硬联合麻醉硬膜外镇痛组各120例,观察两组患者术后36 h内的疼痛程度、神经精神功能以及术前、术后7 d认知功能障碍的发生率。结果：两组术中的ECG、BP、HR、SpO2均在正常范围,无显著差异;术后36 h内,每隔12 h进行1次的VAS评分结果显示,全身麻醉静脉镇痛组的镇痛效果均明显优于腰硬联合麻醉硬膜外镇痛组（P〈0.05）;通过两组手术期MMSE评分比较,腰硬联合麻醉硬膜外镇痛组术后12、24、36 h的MMSE评分均明显高于全身麻醉静脉镇痛组（P〈0.05）;两组术前发生认知功能障碍的患者数量均为0,而腰硬联合麻醉硬膜外镇痛组术后7 d认知功能障碍的发生率明显低于全身麻醉静脉镇痛组（P〈0.05）。结论：老年人术后认知障碍的发病机理尚不明确,还需更深入的研究不同麻药、不同麻醉方法和镇痛方法对老年人术后精神和神经方面的影响,以指导临床合理用药,减少术后不良反应的发生率。     

Postoperative analgesia following total hip replacement: a comparison of intrathecal morphine and diamorphine.

Sixty patients undergoing elective total hip replacement under spinal anaesthesia were randomly assigned to receive either intrathecal (IT) diamorphine 0.75 mg (n = 30) or IT morphine 1.0 mg (n = 30). Postoperative pain scores, analgesic requirements and side effects were assessed by a blinded observer. Postoperative pain scores were broadly similar and satisfactory for both groups but the amount of additional IV morphine required to achieve this was significantly reduced in the morphine compared with the diamorphine group (P < 0.05). Twelve of the morphine group required no postoperative analgesics compared with four in the diamorphine group (P < 0.02). There were no differences between the groups in the incidence of side effects such as emesis and pruritus. No significant postoperative respiratory depression was noted. In the doses used intrathecal morphine provided superior postoperative analgesia to that of intrathecal diamorphine.     

英太青超前镇痛在阻生齿拔除术中的临床疗效分析

目的 分析评价英太青超前镇痛在阻生齿拔除术中的应用。方法 选取进行下颌阻生齿拔除术的患者100例,分为口服英太青的实验组和口服维生素C的对照组,每组各50例。记录患者的疼痛度和睡眠质量,以分析评价英太青超前镇痛在阻生齿拔除术中的临床疗效。结果 对照组患者的疼痛度明显高于实验组,差异有统计学意义(P<0.01);同时实验组的睡眠质量明显高于对照组,差异有统计学意义(P<0.01)。结论 在阻生齿拔除术中,使用英太青超前镇痛,可有效减轻患者术中术后的疼痛,且能改善睡眠。     

不同浓度罗哌卡因复合芬太尼用于开胸术后硬膜外自控镇痛的比较研究

目的比较不同浓度罗哌卡因与芬太尼复合用于开胸术后硬膜外自控镇痛的临床效果。方法将60例ASAⅠ～Ⅱ级择期行肺切除手术病人随机分为三组,每组20例,术毕分别施行不同配方胸段硬膜外镇痛:0.2%罗哌卡因(Ⅰ组);0.15%罗哌卡因/芬太尼4μg/ml(Ⅱ组);0.1%罗哌卡因/芬太尼4μg/ml(Ⅲ组)。观察术后HR、BP变化,VAS评分,总按压次数与实际进药次数之比(D/D),恶心、呕吐、搔痒和尿潴留的发生率,动脉血PaCO2。结果VAS评分Ⅰ组>Ⅱ、Ⅲ组(p<0.01),Ⅱ、Ⅲ组间无显著性差异(p>0.05);按压总数和实进数Ⅰ组>Ⅲ组>Ⅱ组(p<0.01),D/D比值在0～2之间以Ⅱ组最多(p<0.05)。结论0.15%罗哌卡因/芬太尼4μg/ml配方用于开胸术后硬膜外病人自控镇痛(PCEA)可达到满意的临床效果,且副作用较少。     

丙帕他莫复合布托啡诺用于急性创伤术后止痛的效果分析

目的探讨丙帕他莫复合布托啡诺用于急性创伤术后镇痛的效果。方法将50例ASAI级,急性创伤患者分为观察组（n=25）与对照组（n=25）。观察组使用持续性静脉自控镇痛方法,昂丹司琼8rag＋布托啡诺10mg＋丙帕他莫3g,用0．9％生理盐水稀释至100ml,对照组：曲马多缓释片,口服,减轻术后疼痛。观察观察组与对照组患者术后的NKS患者疼痛评分及术后伤口愈合情况。结果对照组NKS明显高于观察组;对照组与实验组患者副作用差异均无无统计学意义;观察组术后伤口愈合、情况明显优于对照组。结论丙帕他莫复合布托啡诺用于急性创伤术后止痛具有良好的效果,副作用少,对伤口愈合情况具有极大的促进作用,减轻了患者的疼痛,提高了手术的成功率。     

Preoperative epidural morphine using double-catheter technique for esophagectomy

This study was undertaken to determine whether preoperative epidural morphine using double-catheter technique would improve postoperative analgesia in patients undergoing esophagectomy with or without continuous intraoperative epidural lidocaine in a randomized double-blind and controlled manner. Thirty patients undergoing esophagectomy for esophageal cancer received preoperative epidural morphine 2 mg at T 6-7 and 2 mg at L 3-4 through the catheters, respectively. Thereafter, continuous thoracic epidural infusion of either 1% lidocaine (lidocaine group, n = 15) or normal saline solution (control group, n = 15) at 6 ml/h was initiated. After surgery, mean verbal rating scale of pain (0 to 10) at rest was maintained below 4 and pain on deep breathing was maintained mild in all patients in both groups. There was no significant difference in these values between the groups. In conclusion, preoperative epidural morphine using double-catheter technique provided adequate analgesia following esophagectomy. The addition of intraoperative continuous epidural lidocaine did not improve analgesia.     

多模式超前镇痛对卵巢囊肿腹腔镜术后疼痛及IL-6的影响

目的探讨多模式超前镇痛对卵巢囊肿腹腔镜术后疼痛及IL-6的影响。方法择期行卵巢囊肿腹腔镜手术的患者100例,随机分为2组(n=50),A组术前30min缓慢静注氯诺昔康8mg,手术开始前以0.238%甲磺酸罗哌卡因15mL+氯诺昔康8mg切口浸润及0.238%罗哌卡因行50mL行手术部位浸润和腹腔喷洒,B组同等容量和浓度甲磺酸罗哌卡因、氯诺昔康在病灶切除后行切口和手术部位浸润及腹腔喷洒,手术结束时静注鲁诺昔康8mg。分别于术前30min、术毕即刻(均未给氯诺昔康时)、术后3、12、24h抽取外周静脉血测白介素-6(IL-6),并于术后不同时点观察疼痛视觉模拟评分(VAS)。结果术后2组间VAS评分有显著差异(P<0.05),A组术后能有效抑制应激反应。结论多模式超前镇痛用于妇科腹腔镜手术,可减轻术后疼痛,减少镇痛药用量,有效抑制术后机体应激反应。     

Should intrathecal narcotics be used as a sole labor analgesic? A prospective comparison of spinal opioids and epidural bupivacaine

OBJECTIVE: Intrathecal narcotics (ITNs) are being used in some settings as a sole labor analgesic. However, they have not been directly compared to epidural analgesia. STUDY DESIGN: We used a prospective observational design. POPULATION: Eighty-two women with uncomplicated full-term pregnancies were enrolled upon analgesia request during spontaneous labor with cervical dilation 3 to 7 cm. Sixty-three chose ITNs (morphine and fentanyl), and 19 chose epidural analgesia (continuous infusion of bupivacaine and fentanyl). OUTCOMES MEASURED: Pain scores were documented using a visual analog scale. Satisfaction and side effects were rated with Likert scales during a structured interview on the first postpartum day. Outcomes were analyzed with multivariate regression techniques. RESULTS: Intrathecal narcotics were associated with significantly higher pain scores than was epidural analgesia during the first and second stages of labor and on an overall postpartum rating. The median effective duration of action for ITNs was between 60 and 120 minutes; however, ITNs provided excellent analgesia for a subgroup of women who delivered within 2 to 3 hours of receiving them. Although women in both groups were satisfied with their pain management, women receiving ITNs had statistically lower overall satisfaction scores. CONCLUSIONS: Within the limitations of a nonrandomized study, a single intrathecal injection of morphine and fentanyl has a shorter duration of action and provides less effective pain control than a continuous epidural infusion of bupivacaine and fentanyl. However, ITNs may have a role in settings with limited support from anesthesiologists or for women whose labors are progressing rapidly.     

Preparing Children for Day Surgery

This study measured the effect of a group preoperative teaching program on the level of children's emotional distress during day surgery. The sample consisted of 30 children, ages 3 through 10, scheduled for elective surgery. One group attended a structured program and received procedural and sensory information within 2 weeks of their surgery. The other group did not receive this intervention. A t test identified significant differences between the groups. Children who attended the preoperative teaching program demonstrated less emotional distress than children who did not receive this intervention. These findings reinforce the positive outcomes of preoperative teaching programs that provide procedural and sensory information to children as preparation for day surgery.     

布托啡诺联合芬太尼应用于开胸手术后患者自控静脉镇痛

目的通过观察布托啡诺联合芬太尼用于开胸手术后患者自控静脉镇痛的效果，探讨两种药物复合应用的安全性。方法90例ASA分级Ⅰ-Ⅱ级的择期开胸手术患者，随机分为三组，每组各30例，即B组（0．15mg／ml布托啡诺）、F组（20阻洲芬太尼）和BF组（0．1mg／ml布托啡诺＋10μg／ml芬太尼）。在手术缝合皮肤前接镇痛泵，记录手术后1、4、8、12、24和48h患者镇痛评分、镇静评分、Bp、HR、R、SpO2、按压次数、镇痛药物消耗量、不良反应的发生情况、患者对镇痛的总体满意度等。结果B组患者在术后1、4、8和12h的镇痛评分均明显高于其他两组，差异有统计学意义（P〈0．05），而F组与BF组镇痛评分在各个时间点比较差异均无统计学意义（P〉0．05）。与F组比较，B组和BF组1、4、8和12h镇静评分较高，但无过度镇静的发生。从患者对镇痛的总体满意度调查看，B组满意度最低，BE组最高，F组略低于BE组。F组患者发生皮肤瘙痒（16．7％）、恶心呕吐（23．3％）的比例较高，B组的镇痛效果较差，但B组及BF组均无皮肤瘙痒的发生。结论布托啡诺联合芬太尼应用于开胸术后患者自控静脉镇痛安全有效，不良反应少，布托啡诺适度的镇静作用成为患者满意度高的主要因素。     

Patient-related risk factors that predict poor outcome after total hip replacement.

OBJECTIVE: To identify factors associated with poor outcome after total hip replacement (THR) surgery. DATA SOURCES: This article is the first to present results from the American Medical Group Association (AMGA) THR consortium. STUDY DESIGN: The outcomes evaluated were pain and physical function. Eight patient risk factors were evaluated. These included the age, sex, race, marital status, and education of the patient; whether the patient had polyarticular disease or other comorbid conditions; and the patient's preoperative pain and physical function score. DATA COLLECTION: Data were collected from patients using AMGA-approved, self-administered questionnaires preoperatively and at six weeks, three months, six months, one year, and two years postoperatively. PRINCIPAL FINDINGS: Of the patient risk factors studied, race, education, number of comorbid conditions, and preoperative Health Status Questionnaire (HSQ) score were found to be associated with poor outcome. These risk factors were found to have an effect on both pain and physical function at six months postoperatively. Patients with higher preoperative scores were found to have higher postoperative scores, but substantially fewer of these patients received any benefit from their surgery. For each 10-point increase in preoperative score, patients could expect at least a 6-point decrease in postoperative improvement. CONCLUSIONS: Our study indicates that preoperative status is an important predictor of outcome for THR.     

右美托咪啶滴鼻用于甲状腺手术的临床观察

目的 观察右美托咪啶滴鼻对全凭静脉麻醉下甲状腺手术术后镇痛效果.方法 60例择期行甲状腺手术的女性患者,按机械抽样法随机分成两组,每组30例.Ⅰ组麻醉诱导前给予右美托咪啶1μg/kg滴鼻,Ⅱ组麻醉诱导前同量氯化钠注射液滴鼻,开皮前10 min氟比洛芬酯100 mg静脉注射.行气管插管全凭静脉麻醉,术后1,2,4,6,8,12,24 h用视觉模拟量表（VAS）评价手术部位的疼痛,布氏舒适量表（BCS）评价咳嗽时疼痛,并记录不良反应.结果 Ⅰ组术后1,2,4,6,8,12h的VAS评分明显低于Ⅱ组,差异有统计学意义（P＜0.05）;Ⅰ组术后1,2,4,6,8h的BCS评分高于Ⅱ组,差异有统计学意义（P＜0.05）;Ⅰ组术后恶心、头晕发生例数低于Ⅱ组（8例比14例、6例比14例）,差异有统计学意义（P＜0.05）;Ⅱ组有8例患者术后12h内追加镇痛药物,明显高于Ⅰ组（0例）,差异有统计学意义（P＜0.05）.结论 在全凭静脉麻醉下甲状腺手术患者给予右美托咪啶1μg/kg滴鼻联合氟比洛芬酯超前镇痛可达到满意的术后镇痛效果,且降低了术后恶心及头晕的发生率,提高了患者术后舒适度.