右美托咪定复合罗哌卡因在下肢骨科手术中的效果观察

目的探讨右美托咪定复合罗哌卡因在下肢骨科手术中的效果观察。方法选取2018年9月～2019年10月我院收治的行下肢骨科手术治疗的66例患者,采用随机数字表法将患者分为A组、B组和C组各22例。A组行罗哌卡因腰骶丛阻滞,B组行右美托咪定复合罗哌卡因腰骶丛阻滞,C组行罗哌卡因腰骶丛阻滞复合静脉输注右美托咪定。对比三组患者阻滞效果和不良发应。结果 A组感觉阻滞起效时间和运动阻滞起效时间均长于C、B组,B组感觉阻滞持续时间和运动阻滞持续时间均长于C、A组(P<0.05);A组不良反应发生率为45.45%,C组为27.27%,B组为4.55%,组间比较,差异显著(P<0.05)。结论右美托咪定静脉使用或加入罗哌卡在下肢骨科手术的应用良好,能有效延长阻滞作用时间,缩短麻醉起效时间,不良反应少,安全可靠。     

相同剂量不同浓度的罗哌卡因用于腰丛坐骨神经联合阻滞的临床研究

目的：观察相同剂量不同浓度的罗哌卡因用于腰丛坐骨神经联合阻滞的临床效果。方法：择期行单侧下肢手术的患者90例,年龄18～65岁,ASAⅠ或Ⅱ级,随机分为3组（n=30）：A组给予0．3％的罗哌卡因腰丛36mL、坐骨神经24mL,B组给予0．36％的罗哌卡因腰丛30mL、坐骨神经24mL,C组给予0．4％罗哌卡因腰丛27mL、坐骨神经18mL。分别于给药后2、5、10、15、20、25、30、35min测定下肢的感觉、运动评分以及感觉阻滞的时间和运动阻滞的时间。结果：三组患者阻滞起效时间无明显差别,高容量组完全阻滞的持续时间短于低容量组;高容量低浓度组患者完全阻滞率高于低容量组,但达到完全阻滞时间长于低容量组。结论：在剂量相同时罗哌卡因的浓度和容量会影响腰丛和坐骨神经的阻滞效果;高容量罗哌卡因更有利于达到良好的感觉阻滞。     

超声引导下肌间沟臂丛神经阻滞的罗哌卡因浓度选择

81例择期单侧上肢手术患者分为A、B、C三组,在超声引导下行肌间沟臂丛神经阻滞,A、B、C三组患者分别给予0.25%、0.375%和05%的罗哌卡因各30ml,观察三组患者注入麻醉药物后15min和30min各部位神经痛觉阻滞情况,统计三组患者的麻醉起效时间、镇痛持续时间和运动阻滞恢复时间,并比较对三组患者的麻醉效果进行评价。麻醉15min后,A组患者各部位神经发生痛觉阻滞的人数明显低于B组和C组,A组患者麻醉起效时间明显较B组和C组长,镇痛持续时间和运动阻恢复时间明显较B组和C组短,P0.05,为差异有统计学意义;但麻醉30min后,三组患者各部位神经发生痛觉阻滞的人数和总麻醉效果比较差异不显著(P0.05)。0.375%的罗哌卡因30ml可缩短麻醉起效时间,且在一定范围内可延长阻滞持续时间。     

不同浓度罗哌卡因颈丛神经阻滞麻醉效果观察

目的比较不同浓度罗哌卡因颈丛神经阻滞麻醉效果。方法选择择期颈部手术患者60例,随机分为两组,每组30例。将罗哌卡因100mg稀释到30ml（0．333％,A组）、40ml（0．25％,B组）。记录两组麻醉的不良反应,感觉、运动阻滞起效时间,阻滞消退时间。结果A组阻滞成功率（97％）明显高于B组（83％）,P〈0．05。A组感觉、运动阻滞起效时间明显长于B组（P〈0．05）,感觉阻滞消退时间A组明显长于B组（P〈0．05）。A、B两组局部麻醉药中毒例数分别为0例和2例。结论颈丛神经阻滞时0．333％罗哌卡因30ml较0．25％罗哌卡因麻醉阻滞成功率更高。     

罗哌卡因用于腰丛-坐骨神经联合阻滞的临床观察

目的：探讨0．5％、0．75％罗哌卡因用于单侧腰丛-坐骨神经联合阻滞的安全性和有效性。方法：64例ASAⅠ～Ⅱ行单侧下肢手术的患者，随机分为两组，每组32例，分别以0．5％和0．75％的罗哌卡因在神经刺激仪定位下行腰丛和坐骨神经阻滞，观察患者给药30min后感觉和运动阻滞效果、阻滞时间及自觉症状。结果：两组患者起效时间无明显差异，但0．75％罗哌卡因组比0．5％罗哌卡因组运动和感觉阻滞维持时间明显延长，差异有显著性，且患者满意率高。结论：0．75％罗哌卡因用于腰丛-坐骨神经联合阻滞时比0．5％罗哌卡因作用更为完善，持续时间更长，较适用于下肢深部手术和术后镇痛。     

神经刺激仪辅助罗哌卡因阻滞麻醉用于老年下肢手术的效果

目的观察神经刺激仪辅助罗哌卡因阻滞麻醉用于老年下肢手术的临床效果。方法将我院拟行单侧下肢手术的老年患者58例随机分为试验组30例和对照组28例。试验组在神经刺激仪引导下采用0.50%罗哌卡因和1.00%利多卡因行腰丛神经联合坐骨神经阻滞麻醉;对照组采用2.00%利多卡因和0.75%罗哌卡因行硬膜外麻醉。比较两组一般情况、麻醉情况、术后禁食及并发症情况。结果两组手术时间及使用止血带时间比较差异无统计学意义(P>0.05)。术中试验组平均动脉压保持在稳定的状态,无明显波动。手术开始时、术中不同时点及术后1 h平均动脉压两组比较差异有统计学意义(P<0.01)。麻醉开始起效时间、维持时间两组比较差异亦有统计学意义(P<0.05)。试验组麻醉后不同时点神经阻滞完善率均高于对照组,但差异无统计学意义(P>0.05)。术后禁食时间及尿潴留发生率两组比较差异有统计学意义(P<0.05)。结论在神经刺激仪定位下0.50%罗哌卡因用于老年下肢手术腰丛神经联合坐骨神经阻滞麻醉效果满意且安全性好。     

腰丛-坐骨神经阻滞在下肢外伤性手术麻醉中的应用

目的:观察单侧腰丛-坐骨神经阻滞用于下肢外伤性手术麻醉的镇痛效果及对血液动力学的影响.方法:40例急诊拟行单侧下肢外伤性手术的病人随机分为两组.A组采用神经刺激器定位技术行腰丛-坐骨神经阻滞,B组选择L2-3或L3-4间隙行硬膜外麻醉.局麻药均用罗哌卡因.记录麻醉前及麻醉后15、30、60、90 min的收缩压(SBP)、舒张压(DBP)和心率(HR),以及针刺疼痛消失时间、术中输液量、术后尿潴留发生率等指标.结果:与麻醉前相比,两组病人的麻醉后血压均下降,B组病人麻醉后各时点的SBP、DBP均明显低于A组:术中B组的晶体输入量,曾用麻黄碱病例数和术后尿潴留发生率均明显高于A组;针刺疼痛消失时间A组显著低于B组.两组病例麻醉效果确切,均无更改麻醉方式完成手术.结论:神经刺激器定位技术下行单侧腰丛-坐骨神经阻滞.麻醉起效快,镇痛效果好,对血液动力学影响小,术后不良反应少,适用于下肢创伤性手术病人.     

不同剂量轻比重罗哌卡因单侧腰麻在高龄髋关节置换术中的效果比较

目的观察不同剂量轻比重罗哌卡因单侧腰麻用于高龄髋关节置换术患者的临床效果及对循环呼吸功能的影响。方法选择70岁以上行人工髋关节置换术的患者60例,随机分为A、B、C 3组,每组20例。于L2-3行腰部蛛网膜下腔和硬膜外联合穿刺后,注入腰麻药(A组为轻比重0.4%罗哌卡因1.2mL,B组为轻比重0.4%罗哌卡因1.5mL,C组为轻比重0.4%罗哌卡因1.8mL)。记录感觉阻滞起效时间、运动阻滞起效时间、最高阻滞平面、麻醉维持时间、最大运动阻滞程度、最大运动阻滞时间、感觉及运动恢复时间,并观察术中用药情况及不良反应。结果 3组患者在感觉阻滞起效时间、最高阻滞平面方面相比差异均无统计学意义(P>0.05)。A、B组的运动阻滞起效时间与C组相比显著延长(P<0.05或P<0.01)。患侧最大Bromage评分、麻醉持续时间、感觉及运动恢复时间:C组>B组>A组(P<0.05或P<0.01)。A组有2例(10%)需硬膜外给药。结论轻比重0.4%罗哌卡因1.5mL单侧腰麻用于老年人髋关节置换手术效果满意、循环稳定、不改变麻醉体位、安全性较高。     

罗哌卡因与布比卡因在腰麻硬膜外麻醉联合阻滞中的效果

目的:探讨罗哌卡因与布比卡因用于腰麻硬膜外麻醉联合阻滞的效果。方法:采用回顾性分析的方法,对依据麻醉药物不同分为罗哌卡因组40例和布比卡因组50例的患者进行分析、比较。结果:布比卡因组感觉阻滞持续时间低于罗哌卡因组(P<0.05),布比卡因组运动起效时间、最大运动阻滞时间低于罗哌卡因组,而最大运动阻滞持续时间高于罗哌卡因组(P<0.05)。结论:罗哌卡因与布比卡因用于腰麻硬膜外麻醉联合阻滞的效果均较为明显,但罗哌卡因对产妇安全有效,值得临床推广应用。     

罗哌卡因与布比卡因及氯普鲁卡因在剖宫产手术腰-硬联合麻醉中的比较

目的比较罗哌卡因、布比卡因和氯普鲁卡因在剖宫产手术腰-硬联合麻醉(CSEA)中的应用效果。方法择期行剖宫产手术产妇120例,随机均分成三组:罗哌卡因组(A)组、布比卡因组(B组)和氯普鲁卡因组(C组),蛛网膜下腔分别给予0.5%罗哌卡因、0.5%布比卡因和1.5%氯普鲁卡因各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;VAS评分评估产妇疼痛程度、术者评定腹壁松驰度、记录其后不良反应。结果 A组产妇感觉阻滞起效时间明显短于B、C组(P<0.05),麻醉持续时间长于B、C组(P<0.05),最高阻滞平面高于B组、低于C组;三组镇痛效果满意,腹壁松驰度"很松"者分别占95%、94%、80%。麻醉后不良反应少。结论与0.5%布比卡因和1.5%氯普鲁卡因比较,0.5%罗哌卡因具有起效快、阻滞完善,能达到满意的肌松效果,适用于剖宫产手术的CSEA中的脊麻。     

超声引导下胸神经阻滞技术应用于肩胛骨骨折手术的镇痛效果观察

目的:探讨超声引导下胸神经阻滞技术对肩胛骨骨折手术患者的镇痛效果。方法:选取我院2018年1月至2019年11月间行肩胛骨骨折择期手术140例患者进行回顾性分析,共分为3组:气管插管全麻32例(G组),全麻联合臂丛阻滞55例(B组),全麻联合臂丛+胸神经阻滞53例(S组)。其中S组分为3个亚组:胸椎旁阻滞19例(S1组),竖脊肌阻滞16例(S2组),椎板阻滞18例(S3组)。分析术中舒芬太尼追加剂量、苏醒室内的视觉模拟评分法(visual analogue scale,VAS)疼痛评分和追加镇痛药物需求率。结果:在术中追加舒芬太尼用量、苏醒室中VAS评分和追加镇痛需求率方面,S组最低,B组和S组显著低于G组,差异具有统计学意义(P<0.05)。3个S亚组之间,差异无统计学意义。结论:肩胛骨骨折手术中,胸神经阻滞可以在全麻联合臂丛阻滞的基础上,进一步增强镇痛效果,3种胸神经阻滞技术镇痛效果相似。     

Paroxysmal Complete Heart Block due to Bradycardia-dependent, "Phase 4" Fascicular Block in a Patient with Sinus Node Dysfunction and Bifascicular Block

A 34-year-old man with ankylosing spondylitis was admitted to the hospital because of syncopal attacks and heart block. Standard ECG, telemetry and an invasive electrophysiologic examination demonstrated right bundle branch block with left anterior fascicular block, sinus node dysfunction with spontaneous slowing of the sinus rate and, as a result, complete infrahisian atrioventricular block in the remaining fascicle at sinus rates below 57 beats per minute. Infrequent supraventricular extrasystoles and abruptly terminated atrial pacing led to the same result. Atrioventricular conduction resumed after three-to-four blocked atrial impulses with successively increasing rate. Pacemaker treatment provided complete symptomatic relief.     

23. Pain in Patients with Cancer

Abstract: Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients’ quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization’s pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.     

Complete Atrioventricular Block with Unwidened QRS Complex During Hyperkalemia

Purkinje and ventricular myocardial fibers are thought to be more sensitive to hyperkalemia than sinoatrial and atrioventricular (AV) nodes, although complete AV block due to hyperkalemia can occur. We describe a case in which hyperkalemia in a patient affected by renal failure is responsible for complete AV block without QRS complex prolongation. Temporary endoventricular pacing was essential in restoration of adequate renal blood flow and excretion of exceeding serum potassium with subsequent normalization of AV conduction.     

Alternation of Right Bundle Branch Block with Beats Showing Normal Conduction and with a Less Complete Right Bundle Branch Block Pattern

We report the case of an 80-year-old man with a preexistent right bundle branch block (RBBB) who underwent dobutamine stress echocardiography. As the sinus cycle length gradually decreased during the stress test, he first developed a 2:1 RBBB pattern alternating with beats showing normal conduction and then an alternating 2:1 less complete and more complete RBBB pattern. An elucidation of the potential mechanism of the latter very rare phenomenon is provided.     

Programmed Chest-Wall Stimulation to Evaluate the Progress of A-V Block After Pacemaker Insertion in Patients with Trifascicular Disease

Twenty six patients (aged 46-80, mean age 64) with bifascicular block in the presence of prolonged H-V interval (trifascicular block), were followed for an average of 31 months after inserting an R-wave inhibited pacemaker (PM) because of syncope and/or dizzy attacks. The underlying rhythm was evaluated at 4-6-month intervals by three different techniques: 1) 12-lead ECG when intrinsic patient rate was faster than PM rate; 2) abrupt PM inhibition (APMI) by the rapid chest-wall stimulation technique, and 3) progressive PM inhibition (PPMI) using a programmed chest-wall stimulation technique capable of decreasing the PM rate gradually to 30 beats/min before complete PM inhibition. In addition, the PPMI allowed the underlying rhythm to be induced and sustained and properly evaluated without any discomfort to the patient. Following PM insertion, 4 patients (15%) developed complete heart block after a mean follow-up of 43 months, and one patient (4%) developed 2nd degree 2:1 A-V block (VX) after 83 months. The P-R interval increased in 5 patients (19%) and decreased in 2 (8%). No change of A-V conduction was found in 9 patients (34%). Three patients developed low atrial rhythm, atrial flutter and atrial fibrillation, respectively (12%). After PM insertion 2 patients still complained of dizziness. None reported syncope. Two patients died during follow-up, both of congestive heart failure (8%). By detection of intrinsic rhythm it was recognized that a long symptomatic paroxysmal phase may precede the development of chronic complete A-V block. Therefore, the insertion of a permanent PM is recommended in patients with unexplained neurologic symptoms and trifascicular disease, without waiting for documented episodes of complete A-V block.     

Exercise Induced Atrioventricular Block with Gap Phenomenon in Atrioventricular Conduction

A 54-year-old man with normal atrioventricuiar (AV) conduction at rest gave a 4-year history of presyncope during exercise. Treadmill testing showed exercise induced AV block. Electrophysiological study demonstrated rate dependent infranodal AV block and abnormal refractory period of the His-Purkinje system. The gap phenomenon in AV conduction occurred during the programmed stimulation. Supernormal conduction could be considered as the mechanism of the gap phenomenon in this patient.     

带状疱疹后神经痛患者应用星状神经节阻滞联合选择性神经根阻滞的疗效观察及对其睡眠质量的影响

目的:观察星状神经节阻滞(Stellate Ganglion Block,SGB)联合选择性神经根阻滞治疗对带状疱疹后神经痛(Post-herpetic Neuralgia,PHN)患者的疗效及睡眠质量的影响.方法:选取2018年9月至2020年7月上海市嘉定区中医医院收治的PHN患者95例作为研究对象,按照随机数字表...     

Paroxysmal AV block in children with normal cardiac anatomy as a cause of syncope

Background: Syncope due to episodes of paroxysmal atrioventricular (AV) block, defined as transient advanced second or third-degree block, is rarely reported in pediatric patients without congenital heart disease.
Methods: We reviewed our institutional arrhythmia database from January 1988 to January 2007 to identify all patients less than 18 years of age with normal cardiac anatomy and episodes of syncope associated with paroxysmal AV block. Demographic and clinical information was collected.
Results: Six patients were identified ( Table I ). Five of the six patients were female, with an average age of 9.3 ± 4.4 years. Patients had episodes of syncope for an average of 5.6 ± 3.3 years prior to diagnosis. All patients had normal physical examinations, electrocardiograms, and echocardiograms. None were on medications known to interfere with AV nodal function, and laboratory evaluation including Lyme titers were negative. Five of the six patients' episodes were atypical for vasovagal syncope (except patient 6). All patients had documented paroxysmal AV block on either inpatient cardiac monitor, Holter monitor, or event recorder at the time of syncope. There was maintenance or acceleration of the sinus rate during episodes of syncope in all patients (mean atrial rate 107 ± 37 bpm). All six patients had permanent transvenous pacemakers implanted with resolution of symptoms over a mean follow-up of 5.2 ± 6.3 years.  

  Table I.
Characteristics of Six Patients with Paroxysmal AV Block