不同剂量氯胺酮对静脉PCA吗啡术后镇痛效果的影响

目的 评价不同剂量氯胺酮对PCA吗啡镇痛效果的影响。方法 对95例病人进行随机、双盲研究:单纯吗啡组(M组):PCA单次给药量吗啡1mg;氯胺酮组1(MK1组):PCA单次给药量吗啡1 mg+氯胺酮0.04 mg/kg;氯胺酮组2(MK2组):PCA单次给药量吗啡1 mg+氯胺酮0.07 mg/kg;PcA锁定时间均为5 min。分别于术后4、8、12、,16、20和24 h观察血压(BP)、心率(HR)、呼吸频率(RR)、疼痛评分(VAS)、镇静评分以及恶心、呕吐、做梦、复视等副作用等。结果 MK1组、MK2组VAS评分比M组低(0～8 h,P<0.05;8～24 h,P<0.01);吗啡消耗量和恶心、呕吐、镇静、做梦及复视等副作用发生率三组之间差异无显著性。结论0.04 mg/kg氯胺酮复合1mg吗啡可提高经腹全子宫切除术病人术后镇痛质量,并且不增加做梦、复视等副作用。     

Epidural morphine and neostigmine for postoperative analgesia after orthopedic surgery

In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 micro g of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 micro g of epidural neostigmine. The groups were demographically the same and did not differ in intraoperative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group ( approximately 11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05). IMPLICATIONS: The combination of epidural morphine and epidural neostigmine resulted in postoperative analgesia (11 h) devoid of side effects, being an alternative analgesic technique in the population studied.     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

Epidural morphine with butorphanol for postoperative analgesia after cesarean delivery

Epidural morphine has been used more and more to provide long-lasting postoperative analgesia after cesarean delivery. However, the incidence of pruritus (20%-93%) and nausea (17%-60%) detract from the usefulness of epidural morphine. The purpose of this study was to evaluate, in 30 patients having epidural anesthesia for cesarean delivery, the analgesic efficacy and side effects when a combination of epidural morphine, a mu-receptor agonist, and butorphanol, a mu-receptor antagonist and kappa-receptor agonist, was administered. After clamping of the umbilical cord, patients received 4 mg epidural morphine with 3 mL of normal saline (group 1), 4 mg epidural morphine with 1 mg butorphanol and 2 mL of normal saline (group 2), or 4 mg epidural morphine with 3 mg butorphanol (group 3). Patients were monitored for 24 h after administration of the study medications. There were no significant differences between the groups in visual analogue pain scores, time to first analgesic request, respiratory rate, or Trieger dot test performance in the 24 h immediately after these epidural injections. There were three patients in group 1 and one patient in group 2 who experienced oxygen saturations less than 90%. (No patients in group 3 developed an oxygen saturation less than 92%.) The patients in group 3 did not require treatment for pruritus or nausea, a response significantly different (P less than 0.001 and P less than 0.05, respectively) from group 1 or group 2.(ABSTRACT TRUNCATED AT 250 WORDS)     

Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction

BACKGROUND AND OBJECTIVES: Epidural analgesia has been shown to provide superior pain control compared with intravenous (IV) opioids after major surgical procedures. In this study, we compared the effect of epidural analgesia and IV morphine patient-controlled analgesia (PCA) on pain relief, duration of hospitalization, oral nutrition, ambulation, and side effects in patients undergoing a major surgical procedure (i.e., unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction). METHODS: Eighteen patients were prospectively randomized to receive either epidural analgesia or PCA during the postoperative period. The intensity of pain was assessed daily by a 100-mm visual analog scale. The total length of hospital stay, time to ambulation, and time to oral nutrition were recorded. RESULTS: The epidural group had significantly lower pain scores at 3 evaluation times through postoperative day number 4 (P < .05). The total length of hospitalization for the epidural group (median, 101 hours) was significantly less than the PCA group (median, 126 hours; P = .0498). The time to first ambulation, time to first bowel sounds, time to tolerating oral nutrition, incidence of nausea/vomiting or pruritus, and time to first flatus were not statistically different between the groups. CONCLUSIONS: These results show that epidural analgesia compared with PCA offered improved pain control after breast reconstruction with immediate transverse rectus abdominis musculocutaneous flap reconstruction. It also resulted in a 25-hour reduction in time of hospitalization.     

Epidural analgesia for postoperative pain

Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.     

Epidural ketamine for postoperative analgesia

Thirty-four patients of ASA physical status I or II scheduled for gall bladder surgery were studied in a comparative prospective trial to evaluate the efficacy of epidural and intramuscular ketamine for postoperative pain relief. They were divided randomly into three groups. Group I (11 patients) received 30 mg intramuscular ketamine. Group II (10 patients) and Group III (13 patients) received 10 and 30 mg ketamine in 10 ml saline respectively, through epidural catheters. Pain was evaluated every two hours for the first 24 hours post-operatively by using a linear analogue pain scale from 0-10. Ketamine was given on the patient's request and whenever the pain score exceeded three. Ketamine produced analgesia in all patients studied. The reduction of pain score after two and four hours in Group I and III was significant when compared to Group II. Seven patients (54 per cent) in Group III did not require further analgesia after the initial injection. However, following 10 mg epidural ketamine or 30 mg IM ketamine, post-operative pain was more frequent. Four patients who received epidural ketamine complained of transient burning pain in the back during injection. No patient developed respiratory depression, psychic disturbance, cardiovascular instability, bladder dysfunction or neurologic deficit. It is concluded that 30 mg epidural ketamine is a safe and effective method for postoperative analgesia.     

Caudal morphine for postoperative analgesia in children: a comparison with caudal bupivacaine and intravenous morphine

We compared the efficacy, duration, and side effects of preservative-free morphine injected into the caudal space in children, with caudal bupivacaine and with intravenous morphine administration for relief of postoperative pain. Forty-six children, ages 1-16 yr, were randomly assigned to receive intravenous morphine (control group), caudal bupivacaine (0.25%, 1 ml/kg), or caudal morphine (0.5 mg/ml, 0.1 mg/kg). In half the patients given caudal morphine, the morphine was mixed with a dose of lidocaine adequate to produce sacral analgesia, to confirm correct caudal injection of the morphine. Caudal injections were performed at the end of surgery. Time until the first required postoperative intravenous morphine dose was recorded for each patient. The duration of analgesia was significantly greater with caudal morphine (median 12 hr, P less than 0.02) than with caudal bupivacaine (median 5 hr), and both were greater than with intravenous morphine in control patients (median 45 min). Urinary retention, pruritis, and nausea appeared with slightly greater frequency in the caudal morphine group, but no delayed respiratory depression occurred. Caudal morphine (0.5 mg/ml, 0.1 mg/kg) provided 8-24 hr of analgesia in children without a significantly greater incidence of side effects than caudal bupivacaine or intravenous morphine.     

Epidural buprenorphine for postoperative analgesia. A controlled comparison with epidural morphine.

In a double-blind controlled study, epidural buprenorphine 0.3 mg was compared with 4 mg of epidural morphine for postoperative pain relief the first 24 hours after major orthopaedic surgery. The degree of analgesia was equal and satisfactory in both groups. Duration of action was 620 minutes with buprenorphine and 580 minutes with morphine, which was not significantly different. The only serious side effects were recorded in the morphine group, with two patients complaining of pruritus and five of urinary retention. In conclusion, epidural buprenorphine did not offer any advantages in preference to morphine for postoperative pain relief following orthopaedic surgery.