椎管内阻滞用于分娩镇痛的研究进展

背景 椎管内阻滞用于分娩镇痛效果可靠,产妇满意度高,在产科麻醉中已经广泛流行.目的 比较不同椎管内阻滞镇痛的方法,探讨分娩镇痛的前景.内容 描述硬膜外阻滞、硬膜外自控镇痛(patient controlled epidural analgesia,PC EA)、腰硬联合阻滞(combined spinal-epidural analgesia,CSEA)、连续蛛网膜下腔阻滞(continuous spinal anesthesia,CSA)在分娩镇痛中的应用;硬膜外阻滞镇痛对产妇的影响;CSEA与PCEA的比较;CSEA潜在的并发症;CSA的神经系统并发症.趋向 椎管内阻滞是实施分娩镇痛较为理想的方法.但是目前仍然没有一种绝对满意、安全、简单的分娩镇痛方法,有关的内容仍需进一步研究.     

Combined intrathecal and epidural magnesium sulfate supplementation of spinal anesthesia to reduce post-operative analgesic requirements: a prospective, randomized, double-blind, controlled trial in patients undergoing major orthopedic surgery

BACKGROUND: New ways of decreasing post-operative analgesic drug requirements are of special interest after major surgery. Magnesium sulfate (MgSO(4)) alters pain processing and reduces the induction and maintenance of central sensitization by blocking the N-methyl-D-aspartate (NMDA) receptor in the spinal cord. We investigated whether supplementation of spinal anesthesia with combined intrathecally and epidurally infused MgSO(4) reduced patients' post-operative analgesia requirements. METHODS: In a randomized, prospective, double-blind, placebo-controlled trial, we enrolled 120 consecutive patients undergoing orthopedic surgery during spinal anesthesia (levobupivacaine and sufentanil). Patients were randomly assigned to receive intrathecal MgSO(4) (94.5 mg, 6.3%), epidural MgSO(4) (2%, 100 mg/h), intrathecal and epidural MgSO(4) combined or spinal anesthesia alone (controls). Post-operative morphine consumption was assessed in all groups by patient-controlled analgesia (PCA). RESULTS: Of the 120 patients enrolled, 103 (86%) completed the study. Morphine consumption at 36 h after surgery was 38% lower in patients receiving spinal anesthesia plus epidural MgSO(4) [- 14.963 mg; 95% confidence interval (CI), - 1.44 to - 28.49 mg], 49% lower in those receiving spinal anesthesia plus intrathecal MgSO(4) (- 18.963 mg; 95% CI, - 5.27 to - 32.65 mg) and 69% lower in the intrathecal-epidural combined group (- 26.963 mg; 95% CI, - 13.73 to - 40.19 mg) relative to control patients receiving spinal anesthesia alone. No complications developed during the post-operative course or at 1 month after surgery. CONCLUSION: In patients undergoing orthopedic surgery, supplementation of spinal anesthesia with combined intrathecal and epidural MgSO(4) significantly reduces patients' post-operative analgesic requirements.     

Maternal satisfaction with single-dose spinal analgesia for labor pain in Indonesia: a landmark study

The purpose of this study was to assess maternal satisfaction with single-dose spinal analgesia for the management of obstetric pain in Indonesian women. The investigation included 62 laboring women with single pregnancy at term, with 45 primigravidas and 17 multigravidas. The participants’ ages ranged from 15 to 29 years. All participants were screened for physical health and were classified as healthy according to the American Society of Anesthesiologists classification system. All 62 parturients received single-dose spinal anesthesia with a 27-gauge pencil-point needle at either the L3–4 or L4–5 intervertebral interspace, with a combination of bupivacaine, 2.5 mg; morphine, 0.25 mg; and clonidine, 45 μg. Maternal satisfaction, duration of pain relief, and side effects were studied. The overall maternal satisfaction with the single-dose spinal technique for labor analgesia in our study group was high, with 50 patients (81%) being very satisfied, and 7 patients (11%) being satisfied with the quality of labor analgesia. Forty-nine patients (79%) stated that they would select single-dose spinal analgesia for pain control in labor in the future. Our study was the first one in Indonesia to assess maternal satisfaction with single-dose spinal analgesia for labor pain. We concluded that single-dose spinal analgesia with a combination of bupivacaine, morphine, and clonidine provided effective labor pain control for Indonesian women, and maternal satisfaction with this technique was very high. This technique is very cost-effective and should be recommended for routine obstetric pain control in Indonesia and other developing countries. Presented in part by doctors Susilo Chandra and Krzysztof M. Kuczkowski at the Annual Meeting of the Society for Obstetric Anesthesia and Perinatology (SOAP) in Banff, Alberta, Canada, May 16–19, 2007.     

Obstetric anesthesia units in Israel: a national questionnaire-based survey

BackgroundThis survey was performed to assess the organization and practice of obstetric anesthesia units in Israel.MethodsA written questionnaire was mailed at the end of December 2005 to all Israeli anesthesia departments providing labor and delivery services in 2005 (n = 25).ResultsA response rate of 100% accounted for 125,340 deliveries. All labor and delivery suites had on-site anesthesia department services. Data are presented as mean (range) or frequency. Eleven hospitals performed 2500–4999 deliveries/year, 6 hospitals 5000–7499 deliveries/year, and 4 hospitals 7500–9999 deliveries/year. The overall cesarean delivery rate was 20% (0–27). Anesthesia for cesarean delivery (elective and emergency combined) was provided by: general anesthesia 15% (0.5–50), epidural 14.5% (0–99.5), spinal 68% (0–98), or combined spinal–epidural technique 0% (0–30). There was an operating room within or immediately adjacent to the labor ward in 16/25 units, including 10/11 units with >5000 deliveries/year. Labor analgesia was provided by epidural techniques in 50% (4–93) and nitrous oxide in 0.5% (0–90) of deliveries. A total of 11 units had 24 h dedicated anesthesiologist coverage, including all units >7500 deliveries but only 3/8 (38%) with 5000–7500 deliveries. Two of the 4 units with >7500 deliveries had no faculty member with formal training in obstetric anesthesia. Written protocols were available for labor analgesia (17/25), post-partum hemorrhage (12/25), aspiration prophylaxis (15/25) and maternal resuscitation (8/25).ConclusionIn this national appraisal of Israeli obstetric anesthesia services, a notable lack of written protocols, wide variations in staffing, and few specifically trained obstetric anesthesia personnel were observed.     

A review of pediatric regional anesthesia practice during a 17-year period in a single institution

BACKGROUND: There is anecdotal evidence of changes in pediatric regional anesthesia (RA) practice. We performed a retrospective review of prospective data on pediatric RA over 17 years in our institution. METHODS: Data were collected from an electronic database for every anesthetic performed between 1989 and 2005. Type of RA, if any, and age of the patient were noted. Patients were divided into two groups: 相似文献   

An intrathecal catheter in a pregnant patient with idiopathic intracranial hypertension: analgesia,monitor and therapy?

Idiopathic intracranial hypertension is important for the obstetric anaesthetist as it is mostly seen in obese women of childbearing age. The incidence is likely to increase as the obesity pandemic grows. Management of labour analgesia in these patients can be complex and requires multidisciplinary input. We successfully managed labour analgesia in a parturient with idiopathic intracranial hypertension with an intrathecal catheter. The possibility of using this catheter as a cerebrospinal fluid drain and pressure monitor was considered and is discussed along with potential complications.     

Use of a 23-gauge continuous spinal catheter for labor analgesia: a case series

Seven women received labor analgesia with 0.125% bupivacaine and fentanyl 2 μg/mL delivered through a new generation of over-the-needle 23-gauge spinal catheters. The first patient was managed with intermittent bolus injections but inadequate pain control prompted a conversion to a continuous infusion for subsequent patients. One patient developed a postdural puncture headache following catheterization for 5 h, but there were no headaches in those who had an indwelling catheter for 8 h or longer. In one patient the catheter was also used to provide anesthesia for cesarean delivery with 0.5% bupivacaine and fentanyl 20 μg. The largest drop in mean arterial blood pressure was 34% which occurred during the intermittent dosing period in the first patient. The mean blood pressure decrease was <25% in the remaining patients. One patient with labor lasting over 17 h developed pain and paresthesia that resolved in 24 h without treatment. Two patients had motor block that necessitated a temporary reduction in rate or discontinuation of the infusion. The continuous spinal catheter appeared to be acceptable to patients but the optimal choice of drugs, concentration, and mode of administration remains to be determined.     

Spinal chordomas — results of treatment over a 17-year period

Summary Among a series of 511 spinal tumours treated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, between September 1977 and August 1994, 23 operations for spinal chordomas in 9 patients (3 females, 6 males) were performed. After an average period of 7±12 months (2 weeks to 5 years) patients presented at an average age of 45±17 years with pain (68%), gait ataxia (14%), motor weakness (9%) or sphincter disturbances (9%). A complete resection was achieved in 11 operations and a subtotal tumour removal in 12 instances. After subtotal removal, 5 tumours were treated postoperatively using local high dose radiotherapy (60–70 Gy). Overall, every chordoma recurred with the passage of time unless en-bloc resection of the tumour had been performed. The recurrence-free interval tended to be longer after radiotherapy. Analysis of postoperative results revealed a significant positive effect of radiotherapy for motor function, pain, Karnofsky score, and survival.In conclusion, en-bloc resection should be performed whenever localization and extension of the tumour allow one to do so. Surgery should be followed by local high dose radiotherapy.     

Large intrathecal volume: a cause of true failed spinal anesthesia

A 37-year-old woman scheduled for postpartum tubal ligation received two intrathecal doses of 2% hyperbaric mepivacaine (44 mg and 40 mg) and a subsequent single dose of 5% hyperbaric lidocaine (62.5 mg). Her sensory level never extended beyond S1. She subsequently underwent an uneventful general anesthetic, and had no residual sensory or motor deficits. An examination of the patient's lumbosacral magnetic resonance imaging (MRI) scan revealed an unusually large thecal volume. A large lumbosacral intrathecal volume may result in significant dilution or poor redistribution of hyperbaric local anesthetic. The final sensory level may be reduced or absent as a result. Intrathecal volume may be the most important non-modifiable factor affecting intrathecal distribution of local anesthetics; however, it cannot be easily measured or predicted. True failed spinal anesthesia should be distinguished from technical mishap, i.e., failing to introduce the anesthetic into the intrathecal space. The differential of a truly failed single-injection spinal anesthetic may include a large thecal volume, dural ectasias, cysts, and simple anatomic sacral restriction. To minimize maldistribution and neurotoxicity, the sum dose of all intrathecal local anesthetics administered for a single procedure should not significantly exceed the maximum recommended single-dose amount.     

Equine-related injury: a retrospective analysis of outcomes over a 10-year period

BACKGROUND: Morbidity and financial loss caused by equine-related injuries may be significant. The purposes of this study were to determine the patterns of equine-related injury and the impact on outcomes. METHODS: A 10-year retrospective review of equine-related injuries was performed. Age, gender, mechanism, injury severity score, Glasgow Coma Score, length of stay, surgical interventions, and mortality were assessed. RESULTS: Of 80 emergency department evaluations, 76 patients were admitted and form the basis of this study. The most frequent mechanism of injury was fall (68%), followed by crush injuries (15%), kicks (8%), and trampling (5%). Musculoskeletal injuries were most common (64%). Thirty-eight (50%) patients required surgical intervention. Thirty-seven (52%) patients were discharged home; 34% required outpatient physical therapy, and 14% required inpatient rehabilitation. The mortality rate was 7%. CONCLUSIONS: Equine-related injuries resulted in significant morbidity; most victims required outpatient or inpatient rehabilitation. The use of preventive strategies may minimize mortality and reduce the financial impact of postinjury morbidity.     

Need for additional anesthesia after single injection spinal analgesia for labor: a retrospective cohort study

BackgroundThere is little information about the use and efficacy of single injection spinal blocks for labor analgesia; specifically, how frequently subsequent analgesia or anesthesia is needed. This study determined how frequently an additional anesthetic intervention was needed in women who received single injection spinal analgesia.MethodsThis retrospective study examined electronic medical records to find all single injection spinal analgesic blocks for labor analgesia over a 14-year (2003–2016) period. Patient and block characteristics and patient outcomes were recorded. The primary outcome was need for an additional anesthetic intervention following single injection spinal for labor analgesia.ResultsFour-hundred-and-twenty-eight patients received single injection spinal blocks for labor and 60 (14.0%) needed an additional anesthetic either for labor analgesia (n=49) or an unexpected procedure (n=11). Two of these (0.5%) required general anesthesia. Parity of zero (nulliparous), a low cervical dilation at the time of the spinal injection, and induction of labor status, were associated with an increased risk of needing an additional anesthetic intervention.ConclusionsThis retrospective review provides evidence that single injection spinal anesthesia may be used for multiparous women with spontaneous labor and more advanced cervical dilation.     

前列腺脓肿12例诊疗分析

目的 总结前列腺脓肿患者的临床表现及影像学特点,提升诊断符合率,同时为临床治疗提供一定的参考.方法 回顾2006年2月至2014年9月本院12例诊断为前列腺脓肿患者的既往病史、临床表现、实验室检查及影像学表现特点,总结其诊疗特点及临床疗效.结果 最常见的临床表现及体征为寒颤、发热及尿路刺激症状;9例尿培养阳性,培养结果以大肠杆菌为主(7/9),穿刺液培养亦以大肠杆菌为主(8/9),其中4例行经直肠超声引导下前列腺穿刺引流术及5例行经尿道前列腺脓肿电切去顶引流术,术后予以抗感染而控制病情;术后随访3个月,其中单纯抗感染治疗复发2例.结论 直肠指诊、PSA、经直肠超声及CT检查有助于尽早诊断前列腺脓肿,CT可准确反应脓肿的大小、位置及分隔情况,可作为诊断前列腺脓肿的常规检查;超声引导下穿刺引流或经尿道前列腺脓肿电切去顶引流术可有效控制病情.     

Anesthetic management of an obstetric patient with MELAS syndrome: case report and literature review

Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS syndrome) is a mitochondrial disorder associated with neurologic, cardiac, neuromuscular, hepatic, metabolic and gastrointestinal dysfunction and potential anesthetic and obstetric complications. The case of a parturient with MELAS syndrome requiring labor analgesia is presented. A Medline literature search limited to the English language was undertaken to review cases of MELAS syndrome. Based on our experience and literature review, parturients with MELAS syndrome appear to benefit from neuraxial analgesia and anesthesia, which blunt excessive oxygen consumption and acidosis.     

Spinal epidural hematoma. Report of a case and review of the literature

We report the case of a thoracic epidural hematoma at the T7-T9 level which occurred after placement of spinal epidural catheter for continuous anaesthesia in acute pancreatitis. The male patient felt a sudden back pain after six days of successful analgesia and became paraplegic 24 hours afterwards. An emergency laminectomy and removal of the hematoma were performed; however, the patient recovered only incompletely.We discuss the clinical signs and symptoms of spinal epidural hematoma as well as its diagnostics and therapy. The controversial views from the literature concernings its etiology are critically reviewed.     

Tuberculous spondylitis: a retrospective study on a series of 12 patients operated on in a 25-year period.

BACKGROUND: The incidence of tuberculous spondylitis, which had declined steadily for over 40 years in our countries, started increasing again in the eighties, paralleling the resurgence of pulmonary tuberculosis. Therefore it has become a matter of discussion in contemporary literature, because it can be a diagnostic challenge and, in spite of its severe neurological complications, it is a potentially curable illness. METHODS: In this retrospective study the authors report their experience concerning 12 patients operated on in a 25-year period because of serious cord compression from thoracic (9 cases) and cervical (1 case) tuberculous spondylitis or from thoracic tubercular epidural lesion (2 cases). Surgical techniques were selected on the basis of the cause of cord compression. Fusion with autologous bone and metallic osteosynthesis was performed in the cervical case (1986); no other patient received spinal instrumentation, and this can be explained with the consideration that all but one cases of Pott's paraplegia were treated in the years 1968-1977. In all of these cases fusion was achieved by means of plaster jackets and prolonged bed rest. Prolonged chemotherapy was systematically administered. RESULTS: Follow-up data collected in 1995 show good and long-lasting results. CONCLUSIONS: They conclude that surgical treatment is required in case of cord compression and results can be excellent even in presence of severe neurological impairment; spinal instrumentation available in our era should be now considered in order to make rehabilitation earlier and morphologic results more satisfactory.     

Delayed respiratory depression associated with 0.15 mg intrathecal morphine for cesarean section: a review of 1915 cases

PURPOSE: A low dose of morphine, given intrathecally is an effective postoperative analgesic technique and is widely used in cesarean section. Delayed respiratory depression is the most feared side effect of this technique. However, this side effect has not been thoroughly reported in the obstetric population. The aim of this study was to describe respiratory depression associated with intrathecal morphine in postcesarean women, and to estimate its incidence. METHODS: We retrospectively reviewed the obstetric anesthesia database at our institution from April 2000 to December 2006. Patients who were given 0.15 mg intrathecal morphine for cesarean section were identified. From this group, we identified patients who developed bradypnea (respiratory rate 相似文献